Provider Demographics
NPI:1821633256
Name:HERNANDEZ, MADISON
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:HERNANDEZ
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 1:4178 HUNTLEIGH DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76904-1405
Mailing Address - Country:US
Mailing Address - Phone:325-315-4601
Mailing Address - Fax:
Practice Address - Street 1:401 S MOUNT JULIET RD STE 235-118
Practice Address - Street 2:
Practice Address - City:MOUNT JULIET
Practice Address - State:TN
Practice Address - Zip Code:37122-6359
Practice Address - Country:US
Practice Address - Phone:615-393-1709
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-08
Last Update Date:2019-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician