Healthcare Provider Details

I. General information

NPI: 1487378725
Provider Name (Legal Business Name): NIDIA HERNANDEZ, LICENSED CLINICAL SOCIAL WORKER, INC.,
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2022
Last Update Date: 09/29/2022
Certification Date: 09/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8700 PERSHING DR UNIT 5103
PLAYA DEL REY CA
90293-8018
US

IV. Provider business mailing address

8700 PERSHING DR UNIT 5103
PLAYA DEL REY CA
90293-8018
US

V. Phone/Fax

Practice location:
  • Phone: 818-378-8132
  • Fax:
Mailing address:
  • Phone: 818-378-8132
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: NIDIA HERNANDEZ
Title or Position: CEO, DIRECTOR
Credential: LCSW, MSW, MPA
Phone: 818-378-8132