Provider Demographics
NPI:1033322417
Name:HERNANDEZ, MYRA LISETTE (LPC)
Entity Type:Individual
Prefix:MRS
First Name:MYRA
Middle Name:LISETTE
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7516 PORTERHOUSE CT
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79911-2244
Mailing Address - Country:US
Mailing Address - Phone:915-703-1415
Mailing Address - Fax:
Practice Address - Street 1:5900 BALCONES DR STE 100
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-4298
Practice Address - Country:US
Practice Address - Phone:915-703-1415
Practice Address - Fax:915-265-0667
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16481101YP2500X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4714040Medicaid
TX029085006Medicaid
TX029085005Medicaid