Provider Demographics
NPI:1710298344
Name:FERNANDEZ-CORONA, CAMILLE AM
Entity Type:Individual
Prefix:MS
First Name:CAMILLE
Middle Name:AM
Last Name:FERNANDEZ-CORONA
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:PO BOX 64
Mailing Address - Street 2:
Mailing Address - City:HERMOSA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90254-0064
Mailing Address - Country:US
Mailing Address - Phone:131-040-6905
Mailing Address - Fax:
Practice Address - Street 1:11835 W OLYMPIC BLVD
Practice Address - Street 2:# 1090
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064-5001
Practice Address - Country:US
Practice Address - Phone:131-040-6905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-29
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS135961041C0700X, 1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool