Basic Information
| Provider Information | |||||||||
| NPI: | 1922585470 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HERNANDEZ | ||||||||
| FirstName: | CARLA | ||||||||
| MiddleName: | I | ||||||||
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| Credential: | QMHS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3872 W 17TH ST | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441093006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7873561656 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3518 W 25TH ST | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2167412241 | ||||||||
| FaxNumber: | 2167393639 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2018 | ||||||||
| LastUpdateDate: | 07/30/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.