Provider Demographics
NPI:1689803082
Name:HERNANDEZ, JULISSA MARY (LCSW)
Entity Type:Individual
Prefix:MS
First Name:JULISSA
Middle Name:MARY
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:JULISSA
Other - Middle Name:MARY
Other - Last Name:MORENO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:JULISSA MARY MORENO
Mailing Address - Street 1:7626 266TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040-1406
Mailing Address - Country:US
Mailing Address - Phone:347-546-7581
Mailing Address - Fax:
Practice Address - Street 1:7901 BROADWAY
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-1329
Practice Address - Country:US
Practice Address - Phone:718-334-1921
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-07
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0806071041C0700X
NY0791781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY246075Medicaid
NY33S128Medicare PIN