MEDICARE: WENDY HERNANDEZ LMSW, LCSW

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	104100000X	Social Worker	071181-1	NY
2	1041C0700X	Clinical Social Worker	SW9500	FL
3	1041C0700X	Clinical Social Worker	44SC05463100	NJ

General Provider Information

NPI Number	:	1497034326
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WENDY HERNANDEZ LMSW, LCSW

Provider Business Mailing Address
First Line	:	1715 RED CEDAR DR APT 12
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33907-7640
Country	:	US
Telephone Number	:	941-544-6208
Fax Number	:

Provider Business Practice Location Address
First Line	:	1715 RED CEDAR DR APT 12
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33907-7640
Country	:	US
Telephone Number	:	941-544-6208
Fax Number	:

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

Provider Enumeration Date	:	08/09/2011
Last Update Date	:	08/09/2011

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