Provider Demographics
NPI:1174197669
Name:REQUENA HERNANDEZ, LUIS JESUS
Entity Type:Individual
Prefix:MR
First Name:LUIS
Middle Name:JESUS
Last Name:REQUENA HERNANDEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 PALM KEY CIR APT 206
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-4672
Mailing Address - Country:US
Mailing Address - Phone:813-330-6832
Mailing Address - Fax:
Practice Address - Street 1:1305 ZELLWOOD DR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-4839
Practice Address - Country:US
Practice Address - Phone:813-330-6832
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-18
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician