Provider Demographics
NPI:1396143160
Name:HERNANDEZ, TABATHA (CADC II)
Entity type:Individual
Prefix:
First Name:TABATHA
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:CADC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 MENDOCINO CT
Mailing Address - Street 2:
Mailing Address - City:ATWATER
Mailing Address - State:CA
Mailing Address - Zip Code:95301-4230
Mailing Address - Country:US
Mailing Address - Phone:209-357-5269
Mailing Address - Fax:209-357-5269
Practice Address - Street 1:508 MENDOCINO CT
Practice Address - Street 2:
Practice Address - City:ATWATER
Practice Address - State:CA
Practice Address - Zip Code:95301-4230
Practice Address - Country:US
Practice Address - Phone:209-357-5269
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-10
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA043271216101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty