Healthcare Provider Details

I. General information

NPI: 1275007635
Provider Name (Legal Business Name): SAMANTHA HERNANDEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2019
Last Update Date: 01/27/2023
Certification Date: 01/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4015 CRESCENT PARK DR
RIVERVIEW FL
33578-3605
US

IV. Provider business mailing address

4015 CRESCENT PARK DR
RIVERVIEW FL
33578-3605
US

V. Phone/Fax

Practice location:
  • Phone: 813-687-5809
  • Fax:
Mailing address:
  • Phone: 813-687-5809
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-23-63747
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: