Provider Demographics
NPI:1265122428
Name:HERNANDEZ MENA, OMAR L
Entity type:Individual
Prefix:
First Name:OMAR
Middle Name:L
Last Name:HERNANDEZ MENA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1407 SE 7TH ST
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33033-5086
Mailing Address - Country:US
Mailing Address - Phone:786-690-9040
Mailing Address - Fax:
Practice Address - Street 1:1407 SE 7TH ST
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33033-5086
Practice Address - Country:US
Practice Address - Phone:786-690-9040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-11
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-269165106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty