Provider Demographics
NPI:1619226768
Name:HERNANDEZ, LIDIA MIRELLA (CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:LIDIA
Middle Name:MIRELLA
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 S CALIFORNIA AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-1858
Mailing Address - Country:US
Mailing Address - Phone:773-522-2010
Mailing Address - Fax:
Practice Address - Street 1:1401 S CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-1858
Practice Address - Country:US
Practice Address - Phone:773-522-2010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-05
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.007819235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist