Provider Demographics
NPI:1104601558
Name:DURAN HERNANDEZ, LIDICE
Entity type:Individual
Prefix:
First Name:LIDICE
Middle Name:
Last Name:DURAN HERNANDEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LIDICE
Other - Middle Name:
Other - Last Name:DURAN HERNANDEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3316 NW 4TH TER
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33993-5607
Mailing Address - Country:US
Mailing Address - Phone:941-441-7474
Mailing Address - Fax:
Practice Address - Street 1:3316 NW 4TH TER
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33993-5607
Practice Address - Country:US
Practice Address - Phone:941-441-7474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-25
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH19352101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty