Provider Demographics
NPI:1013503291
Name:HERNANDEZ, ADRIAN
Entity Type:Individual
Prefix:
First Name:ADRIAN
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 KENMOOR AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-2395
Mailing Address - Country:US
Mailing Address - Phone:616-805-3660
Mailing Address - Fax:
Practice Address - Street 1:360 E BELTLINE AVE NE STE 100
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-1214
Practice Address - Country:US
Practice Address - Phone:616-805-3660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-12
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6352000488103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty