Provider Demographics
NPI:1124454814
Name:HERNANDEZ, ISMAEL (LSW, CADCI)
Entity type:Individual
Prefix:
First Name:ISMAEL
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:LSW, CADCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:626 SPRUCE CREEK DR
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-9716
Mailing Address - Country:US
Mailing Address - Phone:208-250-2879
Mailing Address - Fax:208-454-0749
Practice Address - Street 1:704 ALBANY ST
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-3501
Practice Address - Country:US
Practice Address - Phone:208-454-5133
Practice Address - Fax:208-454-0749
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-25
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLSW-2652104100000X
ORCADCI 04-07-19101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)