Provider Demographics
NPI:1962992065
Name:HERNANDEZ RODRIGUEZ, POLIBIA A
Entity type:Individual
Prefix:
First Name:POLIBIA
Middle Name:A
Last Name:HERNANDEZ RODRIGUEZ
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 1:2100 FRED DAUGHERTY AVE APT F
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-8606
Mailing Address - Country:US
Mailing Address - Phone:862-232-3620
Mailing Address - Fax:
Practice Address - Street 1:2100 FRED DAUGHERTY AVE
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-8606
Practice Address - Country:US
Practice Address - Phone:862-232-3620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-14
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM515953663106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician