Healthcare Provider Details

I. General information

NPI: 1871417634
Provider Name (Legal Business Name): ELLEN HERNANDEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

4626 N 300 W STE 150
PROVO UT
84604-6077
US

IV. Provider business mailing address

PO BOX 50207
PROVO UT
84605-0207
US

V. Phone/Fax

Practice location:
  • Phone: 801-407-4134
  • Fax: 801-877-0864
Mailing address:
  • Phone: 801-407-4134
  • Fax: 801-877-0864

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number14287144-6009
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: