Healthcare Provider Details

I. General information

NPI: 1790481802
Provider Name (Legal Business Name): STEPHANIE MEDINA HERNANDEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2023
Last Update Date: 04/15/2025
Certification Date: 04/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 N MICHIGAN AVE STE 201
CHICAGO IL
60601-7940
US

IV. Provider business mailing address

4000 W MONTROSE AVE # 527
CHICAGO IL
60641-2140
US

V. Phone/Fax

Practice location:
  • Phone: 312-819-7381
  • Fax:
Mailing address:
  • Phone: 708-365-9633
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180.017011
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: