Healthcare Provider Details

I. General information

NPI: 1104518257
Provider Name (Legal Business Name): ANGELA J HERNANDEZ MSW, LSW, LICDC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2023
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1680 NAVE RD SE FL 2
MASSILLON OH
44646-9604
US

IV. Provider business mailing address

625 CLEVELAND AVE NW
CANTON OH
44702-1805
US

V. Phone/Fax

Practice location:
  • Phone: 330-830-8740
  • Fax: 330-830-0912
Mailing address:
  • Phone: 330-455-0374
  • Fax: 330-453-6716

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.2613516
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLICDC.163054
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: