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General NPI Number Information
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NPI Number | 1124454814
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Entity Type | Individual
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Provider Name | ISMAEL HERNANDEZ LSW, CADCI
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Gender | Male
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Dates
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Enumeration Date | 09/25/2013
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Last Update Date | 09/25/2013
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Provider Practice Location Address
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Address Line | 704 ALBANY ST
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City | CALDWELL
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State | ID
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Zip | 83605-3501
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Country | US
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Telephone | 208-454-5133
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Fax | 208-454-0749
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Provider Business Mailing Address
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Address Line | 626 SPRUCE CREEK DR
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City | NAMPA
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State | ID
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Zip | 83686-9716
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Country | US
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Telephone | 208-250-2879
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Fax | 208-454-0749
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | LSW-2652
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | CADCI 04-07-19
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License Number State | OR
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