Provider Demographics
NPI:1548708357
Name:CANCIO HERNANDEZ, TAYRA M
Entity type:Individual
Prefix:
First Name:TAYRA
Middle Name:M
Last Name:CANCIO 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 1:5274 SW 145TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-5732
Mailing Address - Country:US
Mailing Address - Phone:305-910-8421
Mailing Address - Fax:
Practice Address - Street 1:5274 SW 145TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-5732
Practice Address - Country:US
Practice Address - Phone:305-910-8421
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-01
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT16-12426106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician