Provider Demographics
NPI:1366207029
Name:HERNANDEZ PUPO, YESSICA B
Entity type:Individual
Prefix:
First Name:YESSICA
Middle Name:B
Last Name:HERNANDEZ PUPO
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 1:105 VENESSA ST
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33461-6913
Mailing Address - Country:US
Mailing Address - Phone:561-403-3133
Mailing Address - Fax:
Practice Address - Street 1:105 VENESSA ST
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33461-6913
Practice Address - Country:US
Practice Address - Phone:561-403-3133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-20
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT23315821106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician