Provider Demographics
NPI:1184814709
Name:HERNANDEZ, RAUL ANTHONY
Entity Type:Individual
Prefix:
First Name:RAUL
Middle Name:ANTHONY
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 N. RAYMOND AVE
Mailing Address - Street 2:BLDG 2-7
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91103-9110
Mailing Address - Country:US
Mailing Address - Phone:626-396-5920
Mailing Address - Fax:626-204-1943
Practice Address - Street 1:1520 N. RAYMOND AVE
Practice Address - Street 2:BLDG 2-7
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91103-9110
Practice Address - Country:US
Practice Address - Phone:626-396-5920
Practice Address - Fax:626-204-1943
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-30
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health