Healthcare Provider Details

I. General information

NPI: 1154725521
Provider Name (Legal Business Name): MIRNA VERONICA HERNANDEZ SALDIVAR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/14/2014
Last Update Date: 11/13/2020
Certification Date: 11/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

855 N EUCLID AVE
ONTARIO CA
91762-2729
US

IV. Provider business mailing address

855 N EUCLID AVE
ONTARIO CA
91762-2729
US

V. Phone/Fax

Practice location:
  • Phone: 909-983-2020
  • Fax:
Mailing address:
  • Phone: 909-983-2020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW97601
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: