Provider Demographics
NPI:1053006478
Name:HERNANDEZ, AMANDA DIANE (RADT #R1444130921)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:DIANE
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:RADT #R1444130921
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 W LA CADENA DR
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92501-1413
Mailing Address - Country:US
Mailing Address - Phone:951-784-8010
Mailing Address - Fax:
Practice Address - Street 1:1021 W LA CADENA DR
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-1413
Practice Address - Country:US
Practice Address - Phone:951-784-8010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-11
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1444130921101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)