Healthcare Provider Details

I. General information

NPI: 1558879312
Provider Name (Legal Business Name): THOMAS LOUIS HERNANDEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2018
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4790 W POTENZA CT
WEST JORDAN UT
84084-7902
US

IV. Provider business mailing address

4790 W POTENZA CT
WEST JORDAN UT
84084-7902
US

V. Phone/Fax

Practice location:
  • Phone: 913-360-9617
  • Fax:
Mailing address:
  • Phone: 913-360-9617
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number118818
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number11910119-3501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: