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NPI Code Detail

MEDICARE: VIVIAN O. HERNANDEZ PH.D., HSPP

MEDICARE: VIVIAN O. HERNANDEZ PH.D., HSPP
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
1103TC0700XClinical Psychologist20040516AIN

General Provider Information

NPI Number : 1396735064
Entity Type Code : Individual
Provider Name (Legal Business Name) : VIVIAN O. HERNANDEZ PH.D., HSPP
Provider Business Mailing Address
First Line : 909 E STATE BLVD
Second Line :
City : FORT WAYNE
State : IN
Zip : 46805-3404
Country : US
Telephone Number : 260-481-2700
Fax Number : 260-481-2717
Provider Business Practice Location Address
First Line : 909 E STATE BLVD
Second Line :
City : FORT WAYNE
State : IN
Zip : 46805-3404
Country : US
Telephone Number : 260-481-2700
Fax Number : 260-481-2717
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/25/2005
Last Update Date : 07/08/2007

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