Healthcare Provider Details

I. General information

NPI: 1003356296
Provider Name (Legal Business Name): RONALD FERNANDES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2017
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 W TEMPLE ST
LOS ANGELES CA
90026-4915
US

IV. Provider business mailing address

67490 RIO VISTA DR
CATHEDRAL CITY CA
92234-8632
US

V. Phone/Fax

Practice location:
  • Phone: 213-385-5100
  • Fax:
Mailing address:
  • Phone: 909-646-0655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number14111
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCP5873-R
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: