Provider Demographics
NPI:1679356406
Name:FERNELIUS, RACHEL ELIZABETH (LCSW)
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:ELIZABETH
Last Name:FERNELIUS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2480 IRVINE BLVD APT 354
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92782-8037
Mailing Address - Country:US
Mailing Address - Phone:949-751-8443
Mailing Address - Fax:
Practice Address - Street 1:6833 INDIANA AVE STE 101
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-4223
Practice Address - Country:US
Practice Address - Phone:657-346-6319
Practice Address - Fax:951-269-4184
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-15
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9896671041C0700X
CA26096251S00000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No251S00000XAgenciesCommunity/Behavioral Health