Provider Demographics
NPI:1164062691
Name:HERNANDEZ HERNANDEZ, MARINA
Entity Type:Individual
Prefix:
First Name:MARINA
Middle Name:
Last Name:HERNANDEZ HERNANDEZ
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 1:4207 SKY FLOWER LN
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34772-8842
Mailing Address - Country:US
Mailing Address - Phone:786-282-2588
Mailing Address - Fax:
Practice Address - Street 1:4207 SKY FLOWER LN
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34772-8842
Practice Address - Country:US
Practice Address - Phone:786-282-2588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-13
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0-22-13891106E00000X, 106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL103375900Medicaid