Healthcare Provider Details

I. General information

NPI: 1083338446
Provider Name (Legal Business Name): AUDREY MAE SANTOS HERNANDEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2022
Last Update Date: 09/29/2022
Certification Date: 09/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

769 W BLAINE ST STE B
RIVERSIDE CA
92507-3970
US

IV. Provider business mailing address

2420 RIVER RD STE 230624
NORCO CA
92860-2268
US

V. Phone/Fax

Practice location:
  • Phone: 951-358-4705
  • Fax:
Mailing address:
  • Phone: 562-217-8756
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number108548
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: