Provider Demographics
NPI:1609422302
Name:HERNANDEZ, CHANTEL RODRIGUEZ
Entity type:Individual
Prefix:
First Name:CHANTEL
Middle Name:RODRIGUEZ
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 1:541 RAMBLER RD
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95348-3351
Mailing Address - Country:US
Mailing Address - Phone:209-707-5077
Mailing Address - Fax:
Practice Address - Street 1:2772 S MARTIN L KING JR BLVD
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93706-5345
Practice Address - Country:US
Practice Address - Phone:559-265-4818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-18
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASUDR9888101YA0400X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA101YA0400XMedicaid
CASUDR9888OtherCADTP