Provider Demographics
NPI:1275943763
Name:HERNANDEZ, ANGELICA
Entity Type:Individual
Prefix:
First Name:ANGELICA
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:PO BOX 933
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48805-0933
Mailing Address - Country:US
Mailing Address - Phone:517-915-8193
Mailing Address - Fax:
Practice Address - Street 1:913 W HOLMES RD
Practice Address - Street 2:SUIT 227 A&C
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-0426
Practice Address - Country:US
Practice Address - Phone:517-303-4185
Practice Address - Fax:517-579-9932
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-06
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401011899101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6401011899OtherLLP LICENSE