Provider Demographics
NPI:1063469203
Name:HERNANDEZ HACKER, PRISCILLA D (PHD)
Entity type:Individual
Prefix:DR
First Name:PRISCILLA
Middle Name:D
Last Name:HERNANDEZ HACKER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:828 S WASHINGTON ST STE A
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-3055
Mailing Address - Country:US
Mailing Address - Phone:208-883-7766
Mailing Address - Fax:208-883-8062
Practice Address - Street 1:828 S WASHINGTON ST STE A
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-3055
Practice Address - Country:US
Practice Address - Phone:208-883-7766
Practice Address - Fax:208-883-8062
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-30
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY1696103TC0700X
IDPSY202196103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010149290OtherREGENCE BLUE SHIELD PIN
WA380-319OtherDSHS PROVIDER NUMBER
ID1684764Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER