=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982418752
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FERNANDEZ THERAPY GROUP LICENSED CLINICAL SOCIAL WORKER, CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2025
-----------------------------------------------------
Last Update Date | 02/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10810 PARAMOUNT BLVD STE 202
-----------------------------------------------------
City | DOWNEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90241-3351
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-248-3513
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10810 PARAMOUNT BLVD STE 202
-----------------------------------------------------
City | DOWNEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90241-3351
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-248-3513
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. RONNIE FERNANDEZ
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 323-793-3595
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------