Provider Demographics
NPI:1225592108
Name:HERNANDEZ, ILEANA
Entity Type:Individual
Prefix:
First Name:ILEANA
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 ACUARIO
Mailing Address - Street 2:URBANIZACION LOMAS DEL SOL
Mailing Address - City:GURABO
Mailing Address - State:PR
Mailing Address - Zip Code:00778
Mailing Address - Country:US
Mailing Address - Phone:939-717-8333
Mailing Address - Fax:
Practice Address - Street 1:2 ACUARIO
Practice Address - Street 2:URB LOMAS DEL SOL
Practice Address - City:GURABO
Practice Address - State:PR
Practice Address - Zip Code:00778
Practice Address - Country:US
Practice Address - Phone:939-717-8333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-25
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4280103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical