Provider Demographics
NPI:1063713998
Name:HERNANDEZ, NOVELLA G (LADAC)
Entity type:Individual
Prefix:MRS
First Name:NOVELLA
Middle Name:G
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:LADAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4068
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88003-4068
Mailing Address - Country:US
Mailing Address - Phone:575-541-0986
Mailing Address - Fax:575-541-8377
Practice Address - Street 1:1190 FOSTER RD
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-3775
Practice Address - Country:US
Practice Address - Phone:575-541-0986
Practice Address - Fax:575-541-8377
Is Sole Proprietor?:No
Enumeration Date:2010-11-09
Last Update Date:2010-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMT-0135191101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMT-0135191OtherSUBSTANCE ABUSE