Basic Information
| Provider Information | |||||||||
| NPI: | 1548802192 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HERNANDEZ PEREZ | ||||||||
| FirstName: | DOLORES | ||||||||
| MiddleName: | ALICIA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | II | ||||||||
| Credential: | RADT1 | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HERENANDEZ PEREZ | ||||||||
| OtherFirstName: | DOLORES | ||||||||
| OtherMiddleName: | ALICIA | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | II | ||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1400 N JOHNSON AVE STE 101 | ||||||||
| Address2: | |||||||||
| City: | EL CAJON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920201651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6194420722 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2049 SKYLINE DR | ||||||||
| Address2: | |||||||||
| City: | LEMON GROVE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919454221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6194657303 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2019 | ||||||||
| LastUpdateDate: | 10/15/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.