Provider Demographics
NPI:1316609779
Name:FERNANDEZ, MIRIAN (LCSW)
Entity type:Individual
Prefix:
First Name:MIRIAN
Middle Name:
Last Name:FERNANDEZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 HARBOR BLVD
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94002-4018
Mailing Address - Country:US
Mailing Address - Phone:209-331-3722
Mailing Address - Fax:
Practice Address - Street 1:9693 E HIGHWAY 26
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95215-9752
Practice Address - Country:US
Practice Address - Phone:209-774-6405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-12
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1034761041C0700X
CA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical