Provider Demographics
NPI:1306308036
Name:HERNANDEZ, ANGELA RAE (LCSW)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:RAE
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N1184 S WHITE RIVER RD
Mailing Address - Street 2:
Mailing Address - City:WAUTOMA
Mailing Address - State:WI
Mailing Address - Zip Code:54982-9021
Mailing Address - Country:US
Mailing Address - Phone:715-209-1253
Mailing Address - Fax:
Practice Address - Street 1:750 N FREEDOM BLVD
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-1677
Practice Address - Country:US
Practice Address - Phone:801-373-4760
Practice Address - Fax:801-373-0639
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-02
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8732-1231041C0700X
UT13069232-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical