Basic Information
Provider Information | |||||||||
NPI: | 1184789596 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HERNANDEZ | ||||||||
FirstName: | ELIZABETH | ||||||||
MiddleName: | E M | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LSCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1802 W 5TH ST | ||||||||
Address2: | APT 3 | ||||||||
City: | LAWRENCE | ||||||||
State: | KS | ||||||||
PostalCode: | 660444638 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7853049121 | ||||||||
FaxNumber: | 7853049121 | ||||||||
Practice Location | |||||||||
Address1: | 200 MAINE ST STE A | ||||||||
Address2: | BERT NASH COMMUNITY MENTAL HEALTH CENTER | ||||||||
City: | LAWRENCE | ||||||||
State: | KS | ||||||||
PostalCode: | 660441396 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7858439192 | ||||||||
FaxNumber: | 7858439192 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/26/2006 | ||||||||
LastUpdateDate: | 07/09/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LSCSW 2085 | KS | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
ID | Type | State | Issuer | Description | 069328HE | 01 | KS | BCBS | OTHER | 200430750B | 05 | KS |   | MEDICAID |