Provider Demographics
NPI:1306405253
Name:HERNANDEZ, TAMARA IVELISSE (RBT)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:IVELISSE
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2459 FLORIDA ST # 2459
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33406-4406
Mailing Address - Country:US
Mailing Address - Phone:360-318-4095
Mailing Address - Fax:
Practice Address - Street 1:2459 FLORIDA ST
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33406-4406
Practice Address - Country:US
Practice Address - Phone:360-318-4095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-12
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1979293106S00000X
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician