Provider Demographics
NPI:1144766544
Name:HERNANDEZ, NICOLE (BSW)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:BSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1819 N 34TH AVE
Mailing Address - Street 2:
Mailing Address - City:STONE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60165-1023
Mailing Address - Country:US
Mailing Address - Phone:773-574-0716
Mailing Address - Fax:
Practice Address - Street 1:1819 N 34TH AVE
Practice Address - Street 2:
Practice Address - City:STONE PARK
Practice Address - State:IL
Practice Address - Zip Code:60165-1023
Practice Address - Country:US
Practice Address - Phone:773-574-0716
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-10
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILH65562089951101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor