Provider Demographics
NPI:1730961863
Name:HERNANDEZ, MARYENIA R
Entity type:Individual
Prefix:
First Name:MARYENIA
Middle Name:R
Last Name:HERNANDEZ
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 1:475 48TH AVE APT 404
Mailing Address - Street 2:
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11109-5504
Mailing Address - Country:US
Mailing Address - Phone:630-870-8682
Mailing Address - Fax:
Practice Address - Street 1:2631 MERRICK RD STE 302
Practice Address - Street 2:
Practice Address - City:BELLMORE
Practice Address - State:NY
Practice Address - Zip Code:11710-5784
Practice Address - Country:US
Practice Address - Phone:646-741-3593
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-13
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst