Healthcare Provider Details

I. General information

NPI: 1396385068
Provider Name (Legal Business Name): EVA HERNANDEZ L.C.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2020
Last Update Date: 01/10/2020
Certification Date: 01/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

934 W HATCHER RD
PHOENIX AZ
85021-3139
US

IV. Provider business mailing address

PO BOX 5177
PHOENIX AZ
85010-5177
US

V. Phone/Fax

Practice location:
  • Phone: 602-344-6300
  • Fax: 602-344-6301
Mailing address:
  • Phone: 602-344-5651
  • Fax: 602-344-5578

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-17450
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: