Provider Demographics
NPI:1104317486
Name:HERNANDEZ, MELODIE L (CDCA)
Entity type:Individual
Prefix:
First Name:MELODIE
Middle Name:L
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3501 W STATE ROUTE 22 3 APT 3
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:45140-3508
Mailing Address - Country:US
Mailing Address - Phone:513-225-7736
Mailing Address - Fax:
Practice Address - Street 1:1521 WALMART DR STE 901
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OH
Practice Address - Zip Code:45036-8359
Practice Address - Country:US
Practice Address - Phone:513-225-7736
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-23
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH188168101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)