Provider Demographics
NPI:1407370927
Name:GARCIA HERNANDEZ, DIANELYS
Entity Type:Individual
Prefix:
First Name:DIANELYS
Middle Name:
Last Name:GARCIA 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 1:16021 NW 38TH CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33054-6723
Mailing Address - Country:US
Mailing Address - Phone:305-487-3565
Mailing Address - Fax:
Practice Address - Street 1:16021 NW 38TH CT
Practice Address - Street 2:
Practice Address - City:MIAMI GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33054-6723
Practice Address - Country:US
Practice Address - Phone:305-487-3565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-26
Last Update Date:2019-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-18-73972106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL021717300Medicaid