Healthcare Provider Details

I. General information

NPI: 1689803082
Provider Name (Legal Business Name): JULISSA MARY HERNANDEZ LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JULISSA MARY MORENO JULISSA MARY MORENO

II. Dates (important events)

Enumeration Date: 07/07/2009
Last Update Date: 12/13/2023
Certification Date: 12/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7901 BROADWAY
ELMHURST NY
11373-1329
US

IV. Provider business mailing address

7626 266TH ST
NEW HYDE PARK NY
11040-1406
US

V. Phone/Fax

Practice location:
  • Phone: 718-334-1921
  • Fax:
Mailing address:
  • Phone: 347-546-7581
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number080607
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number079178
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: