Healthcare Provider Details

I. General information

NPI: 1316609779
Provider Name (Legal Business Name): MIRIAN FERNANDEZ LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2021
Last Update Date: 11/08/2021
Certification Date: 11/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9693 E HIGHWAY 26
STOCKTON CA
95215-9752
US

IV. Provider business mailing address

310 HARBOR BLVD
BELMONT CA
94002-4018
US

V. Phone/Fax

Practice location:
  • Phone: 209-774-6405
  • Fax:
Mailing address:
  • Phone: 209-331-3722
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number103476
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: