Provider Demographics
NPI:1578043808
Name:HERNANDEZ, VANESSA ENEYDA
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:ENEYDA
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 1:649 E ALBERTONI ST STE 100
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90746-1538
Mailing Address - Country:US
Mailing Address - Phone:310-436-9300
Mailing Address - Fax:
Practice Address - Street 1:649 E ALBERTONI ST STE 100
Practice Address - Street 2:
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90746-1538
Practice Address - Country:US
Practice Address - Phone:310-436-9300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-16
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAACSW83265101YM0800X, 104100000X
CALCSW1151251041C0700X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical