Provider Demographics
NPI:1215579701
Name:HERNANDEZ, DANIEL
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:HERNANDEZ
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 1:1401 N TUSTIN AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-8644
Mailing Address - Country:US
Mailing Address - Phone:949-563-1602
Mailing Address - Fax:
Practice Address - Street 1:1401 N TUSTIN AVE
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-8644
Practice Address - Country:US
Practice Address - Phone:714-833-7535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-16
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1215579701Medicaid