Provider Demographics
NPI:1225701642
Name:HERNANDEZ, MIRANDA MERCEDES
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:MERCEDES
Last Name: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 1:821 E 47TH ST
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85713-5009
Mailing Address - Country:US
Mailing Address - Phone:520-232-2021
Mailing Address - Fax:
Practice Address - Street 1:821 E 47TH ST
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85713-5009
Practice Address - Country:US
Practice Address - Phone:520-232-2021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-30
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INRBT-21-158716106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician