Provider Demographics
NPI:1104654094
Name:HERNANDEZ MIRABAL, JUAN PABLO
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:PABLO
Last Name:HERNANDEZ MIRABAL
Suffix:
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 1:16962 SW 92ND CT
Mailing Address - Street 2:
Mailing Address - City:PALMETTO BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33157-4517
Mailing Address - Country:US
Mailing Address - Phone:786-327-0986
Mailing Address - Fax:
Practice Address - Street 1:16962 SW 92ND CT
Practice Address - Street 2:
Practice Address - City:PALMETTO BAY
Practice Address - State:FL
Practice Address - Zip Code:33157-4517
Practice Address - Country:US
Practice Address - Phone:786-327-0986
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-23
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-24-362733106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician