Provider Demographics
NPI:1710504261
Name:HERNANDEZ, CARLOS DANIEL
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:DANIEL
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 1:17311 NW 24TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33056-4612
Mailing Address - Country:US
Mailing Address - Phone:786-406-3354
Mailing Address - Fax:
Practice Address - Street 1:17311 NW 24TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33056-4612
Practice Address - Country:US
Practice Address - Phone:786-406-3354
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-01
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20-119048106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician