Provider Demographics
NPI:1417238866
Name:FERNANDEZ, MARA NOCEJA (LMFT)
Entity Type:Individual
Prefix:
First Name:MARA
Middle Name:NOCEJA
Last Name:FERNANDEZ
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:855 N EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91762-2729
Mailing Address - Country:US
Mailing Address - Phone:909-983-2020
Mailing Address - Fax:
Practice Address - Street 1:855 N EUCLID AVE
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91762-2729
Practice Address - Country:US
Practice Address - Phone:909-983-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-30
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA120248106H00000X
CA89733106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95-1946482Medicaid