Provider Demographics
NPI:1770094039
Name:HERNANDEZ MEDELLIN, LUISA F (PSYD)
Entity type:Individual
Prefix:
First Name:LUISA
Middle Name:F
Last Name:HERNANDEZ MEDELLIN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2605 SW 133RD AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-7108
Mailing Address - Country:US
Mailing Address - Phone:786-488-9343
Mailing Address - Fax:
Practice Address - Street 1:2020 PONCE DE LEON BLVD STE 1201
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33134-4476
Practice Address - Country:US
Practice Address - Phone:305-917-5414
Practice Address - Fax:305-220-1864
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-13
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY9967103TC2200X, 103T00000X, 103TH0004X, 103TM1800X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities