Provider Demographics
NPI:1679348791
Name:HERNANDEZ, TARA ALECE
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:ALECE
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 1:30 VERONICA LN
Mailing Address - Street 2:
Mailing Address - City:NORTH BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11703-5111
Mailing Address - Country:US
Mailing Address - Phone:631-316-6312
Mailing Address - Fax:
Practice Address - Street 1:900 WHEELER RD
Practice Address - Street 2:
Practice Address - City:HAUPPAUGE
Practice Address - State:NY
Practice Address - Zip Code:11788-2964
Practice Address - Country:US
Practice Address - Phone:631-365-4454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-20
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health