Basic Information
Provider Information | |||||||||
NPI: | 1023347952 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HERNANDEZ | ||||||||
FirstName: | WENDY | ||||||||
MiddleName: | NOHEMY | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | ACSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5628 E SLAUSON AVE | ||||||||
Address2: |   | ||||||||
City: | COMMERCE | ||||||||
State: | CA | ||||||||
PostalCode: | 900402922 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3233189960 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 5628 E SLAUSON AVE | ||||||||
Address2: |   | ||||||||
City: | COMMERCE | ||||||||
State: | CA | ||||||||
PostalCode: | 90040 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3233189960 | ||||||||
FaxNumber: | 3237803211 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/24/2009 | ||||||||
LastUpdateDate: | 07/27/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/27/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 66313 | CA | N |   | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | 101566 | CA | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
ID | Type | State | Issuer | Description | 95-2633765 | 01 | CA | MEDI-CAL | OTHER |