Provider Demographics
NPI:1972287803
Name:MARTIN HERNANDEZ, MELISSA C
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:C
Last Name:MARTIN 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 1:8636 N GRADY AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-1944
Mailing Address - Country:US
Mailing Address - Phone:786-681-2528
Mailing Address - Fax:
Practice Address - Street 1:8636 N GRADY AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-1944
Practice Address - Country:US
Practice Address - Phone:786-681-2528
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-12
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician