Healthcare Provider Details

I. General information

NPI: 1659990794
Provider Name (Legal Business Name): ROSIMAR HERNANDEZ RDT-BCT, LCAT, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2020
Last Update Date: 04/27/2021
Certification Date: 04/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

619 S MARION AVE # 117C
LAKE CITY FL
32025-5808
US

IV. Provider business mailing address

619 S MARION AVE. (117C)
LAKE CITY FL
32025-5808
US

V. Phone/Fax

Practice location:
  • Phone: 646-753-2202
  • Fax:
Mailing address:
  • Phone: 646-753-2202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101200000X
TaxonomyDrama Therapist
License Number001221-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: