Provider Demographics
NPI:1164999025
Name:HERNANDEZ-DUSEK, GLORIA ANN (MASTERS LTD SW)
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:ANN
Last Name:HERNANDEZ-DUSEK
Suffix:
Gender:F
Credentials:MASTERS LTD SW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 INDUSTRIAL PARK RD
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:MI
Mailing Address - Zip Code:49013-1246
Mailing Address - Country:US
Mailing Address - Phone:269-427-7937
Mailing Address - Fax:269-427-5180
Practice Address - Street 1:285 JAMES ST
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-1849
Practice Address - Country:US
Practice Address - Phone:855-869-6900
Practice Address - Fax:269-427-5180
Is Sole Proprietor?:No
Enumeration Date:2018-10-30
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801103173104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker