Provider Demographics
NPI:1013416551
Name:HERNANDEZ, MIRNA ELIZABETH
Entity Type:Individual
Prefix:
First Name:MIRNA
Middle Name:ELIZABETH
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16782 VON KARMAN AVE STE 11
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92606-2417
Mailing Address - Country:US
Mailing Address - Phone:855-223-7123
Mailing Address - Fax:619-550-6368
Practice Address - Street 1:1405 COMMERCIAL WAY STE 120
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93309-0626
Practice Address - Country:US
Practice Address - Phone:855-223-7123
Practice Address - Fax:619-550-6368
Is Sole Proprietor?:No
Enumeration Date:2018-02-11
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV17-46432106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician