Provider Demographics
NPI:1346776572
Name:HERNANDEZ, PAOLA
Entity Type:Individual
Prefix:
First Name:PAOLA
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 1:579 COURTLANDT AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10451-5013
Mailing Address - Country:US
Mailing Address - Phone:718-485-2100
Mailing Address - Fax:
Practice Address - Street 1:579 COURTLANDT AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10451-5013
Practice Address - Country:US
Practice Address - Phone:718-485-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-09
Last Update Date:2017-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY13070519600Medicaid