Healthcare Provider Details

I. General information

NPI: 1497275150
Provider Name (Legal Business Name): MARITZA HERNANDEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2017
Last Update Date: 08/30/2018
Certification Date:
Deactivation Date: 07/23/2018
Reactivation Date: 08/29/2018

III. Provider practice location address

3808 S ANGELINE ST
SEATTLE WA
98118
US

IV. Provider business mailing address

3808 S ANGELINE ST
SEATTLE WA
98118-1712
US

V. Phone/Fax

Practice location:
  • Phone: 206-461-4880
  • Fax:
Mailing address:
  • Phone: 206-461-4880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: