Provider Demographics
NPI:1639644040
Name:HERNANDEZ, WANDA ENIT (LSW)
Entity Type:Individual
Prefix:MRS
First Name:WANDA
Middle Name:ENIT
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 LORTON COURT
Mailing Address - Street 2:
Mailing Address - City:OLD BRIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:08857
Mailing Address - Country:US
Mailing Address - Phone:917-757-7196
Mailing Address - Fax:
Practice Address - Street 1:3010 BORDENTOWN AVE STE B2
Practice Address - Street 2:
Practice Address - City:PARLIN
Practice Address - State:NJ
Practice Address - Zip Code:08859-1181
Practice Address - Country:US
Practice Address - Phone:732-365-3933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-11
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL05520600104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker