Provider Demographics
NPI:1942869904
Name:YANTUCHE-HERNANDEZ, KIMBERLY STEPHANY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:STEPHANY
Last Name:YANTUCHE-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 1:2620 INDUSTRY WAY STE C
Mailing Address - Street 2:
Mailing Address - City:LYNWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90262-4042
Mailing Address - Country:US
Mailing Address - Phone:310-894-1663
Mailing Address - Fax:
Practice Address - Street 1:2620 INDUSTRY WAY STE C
Practice Address - Street 2:
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-4042
Practice Address - Country:US
Practice Address - Phone:310-894-1663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-12
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW90190101YM0800X
171M00000X
CA1101281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator