Provider Demographics
NPI:1750697231
Name:FERNANDEZ, ANGELICA MARIA
Entity type:Individual
Prefix:
First Name:ANGELICA
Middle Name:MARIA
Last Name:FERNANDEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ANGELICA
Other - Middle Name:MARIA
Other - Last Name:PALACIOS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MSW
Mailing Address - Street 1:1126 N GRAND AVE STE D
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91724-1552
Mailing Address - Country:US
Mailing Address - Phone:626-967-1667
Mailing Address - Fax:
Practice Address - Street 1:1126 N GRAND AVE STE D
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91724-1552
Practice Address - Country:US
Practice Address - Phone:626-967-1667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-23
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225400000X, 101YM0800X
CA751721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health