Provider Demographics
NPI:1730911132
Name:HERNANDEZ, DESIREE (MA, LAC)
Entity type:Individual
Prefix:
First Name:DESIREE
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:MA, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69 HOOVER AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-5227
Mailing Address - Country:US
Mailing Address - Phone:954-646-3374
Mailing Address - Fax:
Practice Address - Street 1:17-07 ROMAINE ST
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-2150
Practice Address - Country:US
Practice Address - Phone:201-797-2660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-15
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00815700101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor