Provider Demographics
NPI:1720750839
Name:HERNANDEZ GOMEZ, MAILYN
Entity Type:Individual
Prefix:
First Name:MAILYN
Middle Name:
Last Name:HERNANDEZ GOMEZ
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 1:1490 W 49TH PL STE 401
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-8142
Mailing Address - Country:US
Mailing Address - Phone:786-294-0255
Mailing Address - Fax:786-953-6517
Practice Address - Street 1:1490 W 49TH PL STE 401
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-8142
Practice Address - Country:US
Practice Address - Phone:786-294-0255
Practice Address - Fax:786-953-6517
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-28
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician