Provider Demographics
NPI:1750853552
Name:HERNANDEZ, MIOSOTY (LMT)
Entity Type:Individual
Prefix:
First Name:MIOSOTY
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:488 MARTENSE AVE
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-2505
Mailing Address - Country:US
Mailing Address - Phone:201-274-3688
Mailing Address - Fax:
Practice Address - Street 1:340 RAMAPO VALLEY RD
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:NJ
Practice Address - Zip Code:07436-2711
Practice Address - Country:US
Practice Address - Phone:201-651-9100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-19
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ18KT00584900225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist