Provider Demographics
NPI:1467884841
Name:HERNANDEZ, DIEGO ANTONIO
Entity Type:Individual
Prefix:
First Name:DIEGO
Middle Name:ANTONIO
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 1:290 IOOF AVE
Mailing Address - Street 2:
Mailing Address - City:GILROY
Mailing Address - State:CA
Mailing Address - Zip Code:95020-5204
Mailing Address - Country:US
Mailing Address - Phone:408-846-2154
Mailing Address - Fax:408-842-8815
Practice Address - Street 1:290 I O O F AVE
Practice Address - Street 2:
Practice Address - City:GILROY
Practice Address - State:CA
Practice Address - Zip Code:95020-5204
Practice Address - Country:US
Practice Address - Phone:408-846-2154
Practice Address - Fax:408-842-8815
Is Sole Proprietor?:No
Enumeration Date:2013-08-07
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA96682101YM0800X, 104100000X, 1041C0700X, 101Y00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor