Provider Demographics
NPI:1114340106
Name:HERNANDEZ, MARA ELSIE
Entity Type:Individual
Prefix:
First Name:MARA
Middle Name:ELSIE
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 1:2035 E BALL RD STE 200
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92806-5157
Mailing Address - Country:US
Mailing Address - Phone:714-422-8472
Mailing Address - Fax:
Practice Address - Street 1:2035 E BALL RD STE 200
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92806-5157
Practice Address - Country:US
Practice Address - Phone:714-422-8472
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-27
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1167921041C0700X
CA901221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical