Basic Information
| Provider Information | |||||||||
| NPI: | 1902920416 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HERNANDEZ | ||||||||
| FirstName: | JUAN | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | M.S.W | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21520 PIONEER BLVD | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | HAWAIIAN GARDENS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907162603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5628653644 | ||||||||
| FaxNumber: | 5628655244 | ||||||||
| Practice Location | |||||||||
| Address1: | 21520 PIONEER BLVD | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | HAWAIIAN GARDENS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907162603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5628653466 | ||||||||
| FaxNumber: | 5628655244 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2007 | ||||||||
| LastUpdateDate: | 09/19/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 101YM0800X | ASW 37105 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.