Provider Demographics
NPI:1356074611
Name:HERNANDEZ, ENRIQUE
Entity Type:Individual
Prefix:MR
First Name:ENRIQUE
Middle Name:
Last Name: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 1:10261 SW 72ND ST STE 104
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33173-3023
Mailing Address - Country:US
Mailing Address - Phone:786-773-3654
Mailing Address - Fax:
Practice Address - Street 1:26423 SW 135TH CT
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33032-2558
Practice Address - Country:US
Practice Address - Phone:786-273-5509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-05
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician