Provider Demographics
NPI:1164931945
Name:HERNANDEZ, LISA M (BCABA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 DISSTON AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEOLA
Mailing Address - State:FL
Mailing Address - Zip Code:34715-5506
Mailing Address - Country:US
Mailing Address - Phone:407-480-1887
Mailing Address - Fax:
Practice Address - Street 1:306 DISSTON AVE
Practice Address - Street 2:
Practice Address - City:MINNEOLA
Practice Address - State:FL
Practice Address - Zip Code:34715-5506
Practice Address - Country:US
Practice Address - Phone:407-480-1887
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-25
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-17-40153106S00000X
FL0-22-13759106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0-22-13759OtherBEHAVIOR ANALYST CERTIFICATION BOARD
FL022455100Medicaid