Provider Demographics
NPI:1871365262
Name:HERNANDEZ, CONNIE
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CONNIE
Other - Middle Name:
Other - Last Name:HERNANDEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:11799 SEBASTIAN WAY STE 103
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-0708
Mailing Address - Country:US
Mailing Address - Phone:909-243-7903
Mailing Address - Fax:
Practice Address - Street 1:11799 SEBASTIAN WAY STE 103
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-0708
Practice Address - Country:US
Practice Address - Phone:424-351-5420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-27
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2534140106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician