Provider Demographics
NPI:1760174486
Name:BERNALES, ELIJAH JUSTIN (MA, LMFT)
Entity Type:Individual
Prefix:
First Name:ELIJAH
Middle Name:JUSTIN
Last Name:BERNALES
Suffix:
Gender:M
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92701-4599
Mailing Address - Country:US
Mailing Address - Phone:714-308-5473
Mailing Address - Fax:
Practice Address - Street 1:405 W 5TH ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-4599
Practice Address - Country:US
Practice Address - Phone:714-834-3101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-22
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA131492106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist