Provider Demographics
NPI:1902404593
Name:HERNANDEZ, MELISSA MAURA
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:MAURA
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 1:1908 HIGH RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33461-6158
Mailing Address - Country:US
Mailing Address - Phone:561-543-4307
Mailing Address - Fax:
Practice Address - Street 1:1908 HIGH RIDGE RD
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33461-6158
Practice Address - Country:US
Practice Address - Phone:561-543-4307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-15
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician