Provider Demographics
NPI:1578053237
Name:HERNANDEZ, SHANTELL (RBT-17-34076)
Entity Type:Individual
Prefix:
First Name:SHANTELL
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:RBT-17-34076
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13353 ROUND BARN RD
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60585-7815
Mailing Address - Country:US
Mailing Address - Phone:773-865-6755
Mailing Address - Fax:
Practice Address - Street 1:13353 ROUND BARN RD
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60585-7815
Practice Address - Country:US
Practice Address - Phone:773-865-6755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-17
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL17-34076106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician