Provider Demographics
NPI:1720603921
Name:HERNANDEZ CASEIRO, MARITZA
Entity Type:Individual
Prefix:
First Name:MARITZA
Middle Name:
Last Name:HERNANDEZ CASEIRO
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 1:995 W 74TH ST APT 307
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33014-4759
Mailing Address - Country:US
Mailing Address - Phone:305-998-8532
Mailing Address - Fax:
Practice Address - Street 1:995 W 74TH ST APT 307
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33014-4759
Practice Address - Country:US
Practice Address - Phone:305-998-8532
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-12
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT--20-120848106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLRBT-20-120848Medicaid