Provider Demographics
NPI:1790481802
Name:HERNANDEZ, STEPHANIE MEDINA
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:MEDINA
Last Name:HERNANDEZ
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 W MONTROSE AVE # 527
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60641-2140
Mailing Address - Country:US
Mailing Address - Phone:708-365-9633
Mailing Address - Fax:
Practice Address - Street 1:155 N MICHIGAN AVE STE 201
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60601-7940
Practice Address - Country:US
Practice Address - Phone:312-819-7381
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-01
Last Update Date:2025-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.017011101YM0800X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health