Provider Demographics
NPI:1710765953
Name:HERNANDEZ, SERGIO D
Entity Type:Individual
Prefix:
First Name:SERGIO
Middle Name:D
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 1:16921 NW 75TH CT
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33015-4157
Mailing Address - Country:US
Mailing Address - Phone:786-370-9926
Mailing Address - Fax:
Practice Address - Street 1:19001 SW 106TH AVE STE C103
Practice Address - Street 2:
Practice Address - City:CUTLER BAY
Practice Address - State:FL
Practice Address - Zip Code:33157-7669
Practice Address - Country:US
Practice Address - Phone:786-703-4374
Practice Address - Fax:786-703-4374
Is Sole Proprietor?:No
Enumeration Date:2023-09-19
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBACB855910106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician