Provider Demographics
NPI:1982440640
Name:MEDEROS HERNANDEZ, LIVAN
Entity type:Individual
Prefix:
First Name:LIVAN
Middle Name:
Last Name:MEDEROS HERNANDEZ
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 1:8101 SW 24TH CT APT 106
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33324-5734
Mailing Address - Country:US
Mailing Address - Phone:954-594-3256
Mailing Address - Fax:
Practice Address - Street 1:8101 SW 24TH CT APT 106
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33324-5734
Practice Address - Country:US
Practice Address - Phone:954-594-3256
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-02
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician