Provider Demographics
NPI:1134631070
Name:HERNANDEZ, ODALYS (CCM)
Entity type:Individual
Prefix:
First Name:ODALYS
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:CCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9686 FONTAINEBLEAU BLVD APT 504
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33172-4136
Mailing Address - Country:US
Mailing Address - Phone:786-800-4552
Mailing Address - Fax:
Practice Address - Street 1:3271 NW 7TH ST STE 203
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33125-4141
Practice Address - Country:US
Practice Address - Phone:786-220-6902
Practice Address - Fax:866-726-0526
Is Sole Proprietor?:No
Enumeration Date:2017-11-01
Last Update Date:2017-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCCM100323171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator