Provider Demographics
NPI:1841568250
Name:HERNANDEZ, DAVID ALFONSO (BA, AA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:ALFONSO
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:BA, AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2159 MONTE DIABLO AVE
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95203-1226
Mailing Address - Country:US
Mailing Address - Phone:209-938-7941
Mailing Address - Fax:
Practice Address - Street 1:3601 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95211-0110
Practice Address - Country:US
Practice Address - Phone:209-256-3446
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-13
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD8328365103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst