Provider Demographics
NPI:1700442324
Name:VERDESES HERNANDEZ, NANDA SUSELL
Entity Type:Individual
Prefix:
First Name:NANDA
Middle Name:SUSELL
Last Name:VERDESES HERNANDEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NANDA
Other - Middle Name:SUSELL
Other - Last Name:VERDESES HERNANDEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RBT
Mailing Address - Street 1:9201 NW 114TH ST APT 5
Mailing Address - Street 2:
Mailing Address - City:HIALEAH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33018-4302
Mailing Address - Country:US
Mailing Address - Phone:786-479-5714
Mailing Address - Fax:
Practice Address - Street 1:9201 NW 114TH ST APT 5
Practice Address - Street 2:
Practice Address - City:HIALEAH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33018-4302
Practice Address - Country:US
Practice Address - Phone:786-479-5714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-20
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL19-78225106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty