Provider Demographics
NPI:1912558404
Name:HERNANDEZ AVILA, ANNALIE
Entity Type:Individual
Prefix:
First Name:ANNALIE
Middle Name:
Last Name:HERNANDEZ AVILA
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 1:7315 HARDING AVE APT 15
Mailing Address - Street 2:
Mailing Address - City:MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33141-2726
Mailing Address - Country:US
Mailing Address - Phone:702-287-7849
Mailing Address - Fax:
Practice Address - Street 1:7315 HARDING AVE APT 15
Practice Address - Street 2:
Practice Address - City:MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33141-2726
Practice Address - Country:US
Practice Address - Phone:702-287-7849
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-25
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL103771500106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty