Provider Demographics
NPI:1003356296
Name:FERNANDES, RONALD
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:
Last Name:FERNANDES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67490 RIO VISTA DR
Mailing Address - Street 2:
Mailing Address - City:CATHEDRAL CITY
Mailing Address - State:CA
Mailing Address - Zip Code:92234-8632
Mailing Address - Country:US
Mailing Address - Phone:909-646-0655
Mailing Address - Fax:
Practice Address - Street 1:108 W VICTORIA ST
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90248-3523
Practice Address - Country:US
Practice Address - Phone:310-715-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-07
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
CA14111101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional