Provider Demographics
NPI:1831852508
Name:HERNANDEZ, LUSMILA
Entity type:Individual
Prefix:
First Name:LUSMILA
Middle Name:
Last Name: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 1:8181 NW SOUTH RIVER DR LOT 408
Mailing Address - Street 2:
Mailing Address - City:MEDLEY
Mailing Address - State:FL
Mailing Address - Zip Code:33166-7447
Mailing Address - Country:US
Mailing Address - Phone:786-515-5573
Mailing Address - Fax:
Practice Address - Street 1:8181 NW SOUTH RIVER DR LOT 408
Practice Address - Street 2:
Practice Address - City:MEDLEY
Practice Address - State:FL
Practice Address - Zip Code:33166-7447
Practice Address - Country:US
Practice Address - Phone:786-515-5573
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-19
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-130866106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL109578900Medicaid