Provider Demographics
NPI:1356646905
Name:HERNANDEZ, AMADA N/A (CAC III)
Entity Type:Individual
Prefix:
First Name:AMADA
Middle Name:N/A
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:CAC III
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 4
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:CO
Mailing Address - Zip Code:81047-0004
Mailing Address - Country:US
Mailing Address - Phone:719-691-1635
Mailing Address - Fax:
Practice Address - Street 1:711 BARNES AVE
Practice Address - Street 2:
Practice Address - City:LA JUNTA
Practice Address - State:CO
Practice Address - Zip Code:81050-2138
Practice Address - Country:US
Practice Address - Phone:719-336-6931
Practice Address - Fax:719-336-0478
Is Sole Proprietor?:No
Enumeration Date:2011-01-12
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO7242101YA0400X
CO7218101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)