Provider Demographics
NPI:1942283148
Name:HERNANDEZ, ALFONSO (LCSW)
Entity type:Individual
Prefix:
First Name:ALFONSO
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:737 W CHILDS AVE
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95340-6805
Mailing Address - Country:US
Mailing Address - Phone:209-383-1848
Mailing Address - Fax:209-384-3966
Practice Address - Street 1:1717 LAS VEGAS ST
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95358-5500
Practice Address - Country:US
Practice Address - Phone:209-576-4200
Practice Address - Fax:209-556-5047
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS20714106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ01721ZMedicare ID - Type Unspecified
CAQ43190Medicare UPIN