Provider Demographics
NPI:1336501691
Name:HERNANDEZ, TIMOTHY (LADC I)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:LADC I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:295 SCONTICUT NECK RD
Mailing Address - Street 2:
Mailing Address - City:FAIRHAVEN
Mailing Address - State:MA
Mailing Address - Zip Code:02719-1506
Mailing Address - Country:US
Mailing Address - Phone:508-863-6733
Mailing Address - Fax:
Practice Address - Street 1:295 SCONTICUT NECK RD
Practice Address - Street 2:
Practice Address - City:FAIRHAVEN
Practice Address - State:MA
Practice Address - Zip Code:02719-1506
Practice Address - Country:US
Practice Address - Phone:508-863-6733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-25
Last Update Date:2016-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA11680101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)