Provider Demographics
NPI:1710637020
Name:HERNANDEZ ALFONSO, MARYSLEIDY
Entity Type:Individual
Prefix:
First Name:MARYSLEIDY
Middle Name:
Last Name:HERNANDEZ ALFONSO
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 1:14500 SW 110TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-6626
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12456 SW 127TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-6596
Practice Address - Country:US
Practice Address - Phone:305-382-9474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-28
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZRBT-21-158048106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician