Provider Demographics
NPI:1053846097
Name:HERNANDEZ, MIGUEL ANGEL (LCDC / TSC)
Entity Type:Individual
Prefix:
First Name:MIGUEL
Middle Name:ANGEL
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:LCDC / TSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6846 FORT BEND
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78223
Mailing Address - Country:US
Mailing Address - Phone:210-314-6473
Mailing Address - Fax:210-314-8676
Practice Address - Street 1:3615 CULEBRA ROAD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78228
Practice Address - Country:US
Practice Address - Phone:210-314-6473
Practice Address - Fax:210-314-8676
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-27
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11104101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)