MEDICARE: SANDY HERNANDEZ MS LAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	LAC-21273	AZ

General Provider Information

NPI Number	:	1225752926
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SANDY HERNANDEZ MS LAC

Provider Business Mailing Address
First Line	:	3532 W MARYLAND AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85019-1535
Country	:	US
Telephone Number	:	602-565-3030
Fax Number	:

Provider Business Practice Location Address
First Line	:	45 E MONTEREY WAY STE 201
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85012-2757
Country	:	US
Telephone Number	:	480-489-2866
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/27/2022
Last Update Date	:	09/27/2022

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