Provider Demographics
NPI:1952922825
Name:HERNANDEZ, SIARA
Entity Type:Individual
Prefix:
First Name:SIARA
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 1:3141 NW 47TH TER APT 127
Mailing Address - Street 2:
Mailing Address - City:LAUDERDALE LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33319-6633
Mailing Address - Country:US
Mailing Address - Phone:786-872-1435
Mailing Address - Fax:
Practice Address - Street 1:3141 NW 47TH TER APT 127
Practice Address - Street 2:
Practice Address - City:LAUDERDALE LAKES
Practice Address - State:FL
Practice Address - Zip Code:33319-6633
Practice Address - Country:US
Practice Address - Phone:786-872-1435
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-02
Last Update Date:2020-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLRBT-20-116859Medicaid