Healthcare Provider Details

I. General information

NPI: 1144966359
Provider Name (Legal Business Name): CARLA HERNANDEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2022
Last Update Date: 05/10/2022
Certification Date: 05/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8311 ROOSEVELT RD
FOREST PARK IL
60130-2500
US

IV. Provider business mailing address

8311 ROOSEVELT RD
FOREST PARK IL
60130-2500
US

V. Phone/Fax

Practice location:
  • Phone: 708-771-7000
  • Fax: 708-209-2282
Mailing address:
  • Phone: 630-770-0089
  • Fax: 708-209-2282

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149022507
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: