Provider Demographics
NPI:1417727363
Name:FONTAINA HERNANDEZ, CHEYLA
Entity Type:Individual
Prefix:MISS
First Name:CHEYLA
Middle Name:
Last Name:FONTAINA 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 1:901 S M ST
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33460-5130
Mailing Address - Country:US
Mailing Address - Phone:561-317-8170
Mailing Address - Fax:
Practice Address - Street 1:4440 PGA BLVD STE 600
Practice Address - Street 2:
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33410-6542
Practice Address - Country:US
Practice Address - Phone:561-812-8666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-02
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL23318576106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician