Provider Demographics
NPI:1730472481
Name:HERNANDEZ/OLIVEROS, RAQUEL (M)
Entity Type:Individual
Prefix:MRS
First Name:RAQUEL
Middle Name:
Last Name:HERNANDEZ/OLIVEROS
Suffix:
Gender:F
Credentials:M
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3403 S 12TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-5007
Mailing Address - Country:US
Mailing Address - Phone:414-551-8180
Mailing Address - Fax:
Practice Address - Street 1:3403 S 12TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-5007
Practice Address - Country:US
Practice Address - Phone:414-551-8180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-26
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI200 -228106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist