=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083941553
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUSTIN HERNANDEZ LPCC-S
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2009
-----------------------------------------------------
Last Update Date | 01/17/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6200 ROCKSIDE WOODS BLVD N
-----------------------------------------------------
City | INDEPENDENCE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44131-2333
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-312-1368
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8406 ANTLERS TRL
-----------------------------------------------------
City | NORTH RIDGEVILLE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44039-6403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-261-2027
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | C0800099
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | E.0800099-SUPV
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------