Provider Demographics
NPI:1033805916
Name:MUNDO HERNANDEZ, INGRID LIZETH
Entity Type:Individual
Prefix:
First Name:INGRID
Middle Name:LIZETH
Last Name:MUNDO 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 1:3070 W DEL MONTE DR APT 83
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92804-1753
Mailing Address - Country:US
Mailing Address - Phone:657-342-5618
Mailing Address - Fax:
Practice Address - Street 1:3070 W DEL MONTE DR APT 83
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92804-1753
Practice Address - Country:US
Practice Address - Phone:657-342-5618
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-13
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician