Provider Demographics
NPI:1558842567
Name:HERNANDEZ, MIGUEL (R1226930416)
Entity Type:Individual
Prefix:
First Name:MIGUEL
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:R1226930416
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:514 W ARBOR VITAE ST APT 2
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90301-3155
Mailing Address - Country:US
Mailing Address - Phone:310-251-2441
Mailing Address - Fax:
Practice Address - Street 1:907 PICO BLVD
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90405-1326
Practice Address - Country:US
Practice Address - Phone:310-314-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-27
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1226930416101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)