Healthcare Provider Details

I. General information

NPI: 1255014858
Provider Name (Legal Business Name): MARY AMANDA HERNANDEZ CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2023
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3636 CAMINO DEL RIO N STE 101
SAN DIEGO CA
92108-1722
US

IV. Provider business mailing address

1607 ROBINSON AVE
SAN DIEGO CA
92103-4505
US

V. Phone/Fax

Practice location:
  • Phone: 619-928-1293
  • Fax: 619-923-7522
Mailing address:
  • Phone: 949-534-5270
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP36192
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: