Provider Demographics
NPI:1043301278
Name:HERNANDEZ, MARA (LPC)
Entity Type:Individual
Prefix:
First Name:MARA
Middle Name:
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 1:1105 WHITAKER LN
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79902-2126
Mailing Address - Country:US
Mailing Address - Phone:915-533-1929
Mailing Address - Fax:877-587-9452
Practice Address - Street 1:1105 WHITAKER LN
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902-2126
Practice Address - Country:US
Practice Address - Phone:915-533-1929
Practice Address - Fax:877-587-9452
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15728101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX028876302Medicaid
TX7042LCOtherBXBS