Provider Demographics
NPI:1205221439
Name:HERNANDEZ, NICOLE CHRISTINE (PHD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:CHRISTINE
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 W HAMILTON ST
Mailing Address - Street 2:
Mailing Address - City:RUSHVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62681-1371
Mailing Address - Country:US
Mailing Address - Phone:734-673-1672
Mailing Address - Fax:
Practice Address - Street 1:210 S RANDOLPH ST
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:IL
Practice Address - Zip Code:61455-3828
Practice Address - Country:US
Practice Address - Phone:734-673-1672
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-03
Last Update Date:2015-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.008971103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical