Provider Demographics
NPI: | 1821766924 |
---|---|
Name: | HERNANDEZ, MELISSA ALEJANDRA |
Entity Type: | Individual |
Prefix: | |
First Name: | MELISSA |
Middle Name: | ALEJANDRA |
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: | 3031 S VERMONT AVE |
Mailing Address - Street 2: | |
Mailing Address - City: | LOS ANGELES |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 90007-3033 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 323-373-2400 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 3787 S VERMONT AVE |
Practice Address - Street 2: | |
Practice Address - City: | LOS ANGELES |
Practice Address - State: | CA |
Practice Address - Zip Code: | 90007-4203 |
Practice Address - Country: | US |
Practice Address - Phone: | 323-766-2345 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2021-09-02 |
Last Update Date: | 2024-04-04 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
225400000X, 390200000X | ||
CA | 112220 | 1041C0700X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No | 225400000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner | |
No | 390200000X | Student, Health Care | Student in an Organized Health Care Education/Training Program |