Provider Demographics
NPI:1932558616
Name:HERNANDEZ, MARIELA
Entity Type:Individual
Prefix:
First Name:MARIELA
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 1:13241 SW 17TH LN APT 6
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-7619
Mailing Address - Country:US
Mailing Address - Phone:786-394-7807
Mailing Address - Fax:305-742-2190
Practice Address - Street 1:13241 SW 17TH LN APT 6
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-7619
Practice Address - Country:US
Practice Address - Phone:786-394-7807
Practice Address - Fax:305-742-2190
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-03
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLRBT 15-08454Medicaid