Provider Demographics
NPI:1780347179
Name:BORGES HERNANDEZ, MELISSA MARIAM
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:MARIAM
Last Name:BORGES 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 1:444 ALEMEDA DR
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33461-1504
Mailing Address - Country:US
Mailing Address - Phone:561-371-7541
Mailing Address - Fax:
Practice Address - Street 1:6415 LAKE WORTH RD STE 204
Practice Address - Street 2:
Practice Address - City:GREENACRES
Practice Address - State:FL
Practice Address - Zip Code:33463-2904
Practice Address - Country:US
Practice Address - Phone:561-771-9561
Practice Address - Fax:800-766-3139
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-21
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-21-178582106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL111296500Medicaid