Healthcare Provider Details

I. General information

NPI: 1639232895
Provider Name (Legal Business Name): MS. WANDA LUCIA HERNANDEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1440 E 1ST ST
SANTA ANA CA
92701-6384
US

IV. Provider business mailing address

5285 HEATHERLY LN
HUNTINGTON BEACH CA
92649-3675
US

V. Phone/Fax

Practice location:
  • Phone: 714-953-4455
  • Fax:
Mailing address:
  • Phone: 714-953-4455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberIMF39803
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: