Basic Information
Provider Information | |||||||||
NPI: | 1225380512 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BERNAL | ||||||||
FirstName: | ELISA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | AMFT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | CARDOSO-HURTADO | ||||||||
OtherFirstName: | ELISA | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 864 E SANTA CLARA STREET | ||||||||
Address2: |   | ||||||||
City: | VENTURA | ||||||||
State: | CA | ||||||||
PostalCode: | 93001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8056431446 | ||||||||
FaxNumber: | 8054820987 | ||||||||
Practice Location | |||||||||
Address1: | 864 E SANTA CLARA STREET | ||||||||
Address2: |   | ||||||||
City: | VENTURA | ||||||||
State: | CA | ||||||||
PostalCode: | 93001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8056431446 | ||||||||
FaxNumber: | 8054820987 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/10/2012 | ||||||||
LastUpdateDate: | 04/15/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: | 07/18/2018 | ||||||||
NPIReactivationDate: | 04/15/2020 | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/15/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X |   |   | N |   | Behavioral Health & Social Service Providers | Behavioral Analyst |   | 106H00000X | AMFT112571 | CA | Y |   | Behavioral Health & Social Service Providers | Marriage & Family Therapist |   |
No ID Information.