Provider Demographics
NPI:1114745338
Name:HERNANDEZ REINOSO, LADY MARIAM
Entity type:Individual
Prefix:
First Name:LADY
Middle Name:MARIAM
Last Name:HERNANDEZ REINOSO
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 1:17864 SW 107TH AVE APT 5
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33157-5174
Mailing Address - Country:US
Mailing Address - Phone:786-928-9315
Mailing Address - Fax:
Practice Address - Street 1:17864 SW 107TH AVE APT 5
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33157-5174
Practice Address - Country:US
Practice Address - Phone:786-928-9315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-26
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-363969106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician