Provider Demographics
NPI:1639689607
Name:HERNANDEZ, THOMAS R (RADT)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:R
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4445 BURNS AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90029-2702
Mailing Address - Country:US
Mailing Address - Phone:323-222-1440
Mailing Address - Fax:
Practice Address - Street 1:4445 BURNS AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90029-2702
Practice Address - Country:US
Practice Address - Phone:323-222-1440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-04
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1237960916101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)