Provider Demographics
NPI:1295560142
Name:HERNANDEZ, ELYSSA (LPC-ASSOCIATE)
Entity type:Individual
Prefix:
First Name:ELYSSA
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:LPC-ASSOCIATE
Other - Prefix:
Other - First Name:ELYSSA
Other - Middle Name:
Other - Last Name:WHALEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC-ASSOCIATE
Mailing Address - Street 1:220 E BROADWAY AVE APT 1132
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-1346
Mailing Address - Country:US
Mailing Address - Phone:682-847-9160
Mailing Address - Fax:
Practice Address - Street 1:220 E BROADWAY AVE APT 1132
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-1346
Practice Address - Country:US
Practice Address - Phone:682-847-9160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-02
Last Update Date:2024-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX92854101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional