Provider Demographics
NPI:1639232895
Name:HERNANDEZ, WANDA LUCIA
Entity Type:Individual
Prefix:MS
First Name:WANDA
Middle Name:LUCIA
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 1:5285 HEATHERLY LN
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92649-3675
Mailing Address - Country:US
Mailing Address - Phone:714-953-4455
Mailing Address - Fax:
Practice Address - Street 1:1440 E 1ST ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-6384
Practice Address - Country:US
Practice Address - Phone:714-953-4455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF39803106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist