Provider Demographics
NPI:1861215428
Name:HERNANDEZ, ANGEL R SR
Entity type:Individual
Prefix:
First Name:ANGEL
Middle Name:R
Last Name:HERNANDEZ
Suffix:SR
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 1:4600 OAKCREEK ST APT 300
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32835-2877
Mailing Address - Country:US
Mailing Address - Phone:469-987-1472
Mailing Address - Fax:
Practice Address - Street 1:4600 OAKCREEK ST APT 300
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32835-2877
Practice Address - Country:US
Practice Address - Phone:469-987-1472
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-04
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-390006106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician