Provider Demographics
NPI:1336918226
Name:HERNANDEZ, MELODY
Entity type:Individual
Prefix:
First Name:MELODY
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21935 VAN BUREN ST. A1
Mailing Address - Street 2:
Mailing Address - City:GRAND TERRACE
Mailing Address - State:CA
Mailing Address - Zip Code:92313
Mailing Address - Country:US
Mailing Address - Phone:909-906-1023
Mailing Address - Fax:
Practice Address - Street 1:21935 VAN BUREN ST # A1
Practice Address - Street 2:
Practice Address - City:GRAND TERRACE
Practice Address - State:CA
Practice Address - Zip Code:92313-5652
Practice Address - Country:US
Practice Address - Phone:909-906-1023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-20
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician