Basic Information
| Provider Information | |||||||||
| NPI: | 1316340193 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HERNANDEZ | ||||||||
| FirstName: | EDGAR | ||||||||
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| Credential: | MSW, MPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5222 COSUMNES DR APT 132 | ||||||||
| Address2: | |||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952197213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108797576 | ||||||||
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| Practice Location | |||||||||
| Address1: | 470 CHADBOURNE RD STE E | ||||||||
| Address2: | |||||||||
| City: | FAIRFIELD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945349620 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074259670 | ||||||||
| FaxNumber: | 7074259880 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2014 | ||||||||
| LastUpdateDate: | 03/09/2015 | ||||||||
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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 | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.