Provider Demographics
NPI:1326395146
Name:HERNANDEZ - HARRIS, ANGELA MARIA (MA, NCC, LCPC)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:MARIA
Last Name:HERNANDEZ - HARRIS
Suffix:
Gender:F
Credentials:MA, NCC, LCPC
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:MARIA
Other - Last Name:HERNANDEZ - HENRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, NCC, LCPC
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-381-8866
Mailing Address - Fax:
Practice Address - Street 1:115 W MAIN ST STE 203
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-7303
Practice Address - Country:US
Practice Address - Phone:208-381-8330
Practice Address - Fax:208-381-1600
Is Sole Proprietor?:No
Enumeration Date:2012-08-10
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-5805101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1326395146.Medicaid