Provider Demographics
NPI:1134753601
Name:HERNANDEZ, LUIS ARIEL
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:ARIEL
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 1:4301 LUDI MAE CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28227-6638
Mailing Address - Country:US
Mailing Address - Phone:704-837-6440
Mailing Address - Fax:
Practice Address - Street 1:6000 FAIRVIEW RD # 1259
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-2224
Practice Address - Country:US
Practice Address - Phone:704-837-6440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-24
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health