Provider Demographics
NPI:1437424355
Name:HERNANDEZ, ELSA MARIE
Entity Type:Individual
Prefix:
First Name:ELSA
Middle Name:MARIE
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 1:2025 E DAKOTA AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93726-4804
Mailing Address - Country:US
Mailing Address - Phone:559-600-5755
Mailing Address - Fax:
Practice Address - Street 1:2025 E DAKOTA AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93726-4804
Practice Address - Country:US
Practice Address - Phone:559-600-5755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-09
Last Update Date:2017-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA760881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1437424355Medicaid