Provider Demographics
NPI:1609386762
Name:HERNANDEZ, JOSE VICENTE
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:VICENTE
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 1:17650 NW 73RD AVE APT 208
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33015-6232
Mailing Address - Country:US
Mailing Address - Phone:786-587-6391
Mailing Address - Fax:
Practice Address - Street 1:500 FAIRWAY DR STE 102
Practice Address - Street 2:
Practice Address - City:DEERFIELD BEACH
Practice Address - State:FL
Practice Address - Zip Code:33441-1817
Practice Address - Country:US
Practice Address - Phone:786-587-6391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-03
Last Update Date:2017-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty