Provider Demographics
NPI:1811572159
Name:HERNANDEZ, AUDREY SAVANNA
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:SAVANNA
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 1:79440 AVENUE 42 APT 2
Mailing Address - Street 2:
Mailing Address - City:BERMUDA DUNES
Mailing Address - State:CA
Mailing Address - Zip Code:92203-1400
Mailing Address - Country:US
Mailing Address - Phone:760-984-3258
Mailing Address - Fax:
Practice Address - Street 1:73271 FRED WARING DR STE 102
Practice Address - Street 2:
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92260-2889
Practice Address - Country:US
Practice Address - Phone:760-469-9650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-17
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician