Provider Demographics
NPI:1003672064
Name:HERNANDEZ MIRABAL, ANA LIDIA
Entity Type:Individual
Prefix:
First Name:ANA
Middle Name:LIDIA
Last Name:HERNANDEZ MIRABAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8664 FORT SHEA AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32822-7494
Mailing Address - Country:US
Mailing Address - Phone:732-619-8016
Mailing Address - Fax:
Practice Address - Street 1:3104 ORANOLE RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32810-2017
Practice Address - Country:US
Practice Address - Phone:407-501-0494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-26
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24-320710106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician