Provider Demographics
NPI:1619404142
Name:HERNANDEZ, THERESA DENISE
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:DENISE
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 1:11547 BURBANK BLVD APT 3
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91601-2314
Mailing Address - Country:US
Mailing Address - Phone:818-752-2710
Mailing Address - Fax:
Practice Address - Street 1:11547 BURBANK BLVD APT 3
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91601-2314
Practice Address - Country:US
Practice Address - Phone:818-752-2710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician