Basic Information
| Provider Information | |||||||||
| NPI: | 1629743810 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HERNANDEZ | ||||||||
| FirstName: | TERESA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18402 HALSTED ST APT 31 | ||||||||
| Address2: | |||||||||
| City: | NORTHRIDGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913254903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8186890765 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11565 LAUREL CANYON BLVD STE 116 | ||||||||
| Address2: | |||||||||
| City: | SAN FERNANDO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913404650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8183615030 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2021 | ||||||||
| LastUpdateDate: | 08/31/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 96247 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 104100000X | 96247 | CA | N | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.