Provider Demographics
NPI:1891049664
Name:HERNANDEZ, ILEANA IVETTE (LICSW, LADCI)
Entity type:Individual
Prefix:
First Name:ILEANA
Middle Name:IVETTE
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:LICSW, LADCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 MANSFIELD ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01108-2209
Mailing Address - Country:US
Mailing Address - Phone:413-426-1321
Mailing Address - Fax:413-238-6461
Practice Address - Street 1:133 MAPLE ST STE 201
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01105-1896
Practice Address - Country:US
Practice Address - Phone:413-225-1197
Practice Address - Fax:413-238-6461
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-01
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4722101YM0800X
1041C0700X
MA1252161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1851444616Medicaid