Provider Demographics
NPI:1336910553
Name:HERNANDEZ, MICHELLE
Entity Type:Individual
Prefix:MISS
First Name:MICHELLE
Middle Name:
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 1:12702 SW 228TH ST
Mailing Address - Street 2:
Mailing Address - City:GOULDS
Mailing Address - State:FL
Mailing Address - Zip Code:33170-2753
Mailing Address - Country:US
Mailing Address - Phone:863-349-6840
Mailing Address - Fax:
Practice Address - Street 1:12702 SW 228TH ST
Practice Address - Street 2:
Practice Address - City:GOULDS
Practice Address - State:FL
Practice Address - Zip Code:33170-2753
Practice Address - Country:US
Practice Address - Phone:863-349-6840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-16
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-321919106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician