Provider Demographics
NPI:1932465846
Name:HERNANDEZ, RAUL LUIS
Entity Type:Individual
Prefix:
First Name:RAUL
Middle Name:LUIS
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 1:1721 EAST PINE AVENUE
Mailing Address - Street 2:
Mailing Address - City:EL SEGUNDO
Mailing Address - State:LOS ANGELES
Mailing Address - Zip Code:90245
Mailing Address - Country:UM
Mailing Address - Phone:310-706-1273
Mailing Address - Fax:
Practice Address - Street 1:431 W COMPTON BLVD
Practice Address - Street 2:
Practice Address - City:COMPTON
Practice Address - State:CA
Practice Address - Zip Code:90220-3008
Practice Address - Country:US
Practice Address - Phone:424-785-5689
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-04
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARI-H1204021303101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)