MEDICARE: MARISA HERNANDEZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1386474773
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARISA HERNANDEZ

Provider Business Mailing Address
First Line	:	126 W ALEY WAY
Second Line	:
City	:	WICHITA
State	:	KS
Zip	:	67204-5230
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5311 TIN ROOF WAY
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27616-6734
Country	:	US
Telephone Number	:	919-745-8892
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/01/2024
Last Update Date	:	08/01/2024

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Directions to “ MARISA HERNANDEZ ” Practice Location

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