Healthcare Provider Details

I. General information

NPI: 1972190858
Provider Name (Legal Business Name): BIANCA HERNANDEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2020
Last Update Date: 12/28/2020
Certification Date: 12/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

542 S DEARBORN ST STE 580
CHICAGO IL
60605-1573
US

IV. Provider business mailing address

542 S DEARBORN ST STE 580
CHICAGO IL
60605-1573
US

V. Phone/Fax

Practice location:
  • Phone: 708-942-1716
  • Fax: 708-320-8917
Mailing address:
  • Phone: 708-942-1716
  • Fax: 708-320-8917

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178016438
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: