Provider Demographics
NPI:1811763857
Name:HERNANDEZ, ULISES III
Entity type:Individual
Prefix:
First Name:ULISES
Middle Name:
Last Name:HERNANDEZ
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8001 SW 36TH ST STE 9
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33328-1915
Mailing Address - Country:US
Mailing Address - Phone:954-577-7790
Mailing Address - Fax:954-577-7780
Practice Address - Street 1:8001 SW 36TH ST STE 9
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33328-1915
Practice Address - Country:US
Practice Address - Phone:954-577-7790
Practice Address - Fax:954-577-7780
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-30
Last Update Date:2024-06-04
Deactivation Date:2024-05-07
Deactivation Code:
Reactivation Date:2024-06-04
Provider Licenses
StateLicense IDTaxonomies
FLH655840003910106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician