MEDICARE: LIZBETH HERNANDEZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	222Q00000X	Developmental Therapist		IL

General Provider Information

NPI Number	:	1225673692
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LIZBETH HERNANDEZ

Provider Business Mailing Address
First Line	:	1522 CARDINAL AVE
Second Line	:
City	:	MELROSE PARK
State	:	IL
Zip	:	60160-2604
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1346 W GEORGE ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-6624
Country	:	US
Telephone Number	:	708-513-2141
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/08/2019
Last Update Date	:	11/08/2019

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Directions to “ LIZBETH HERNANDEZ ” Practice Location

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