Basic Information
| Provider Information | |||||||||
| NPI: | 1972067023 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HERNANDEZ | ||||||||
| FirstName: | RAYMOND | ||||||||
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| Credential: | CO60274830 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 367 | ||||||||
| Address2: | |||||||||
| City: | TOPPENISH | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989480367 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098655121 | ||||||||
| FaxNumber: | 5098654333 | ||||||||
| Practice Location | |||||||||
| Address1: | 20 GUNNYON RD. | ||||||||
| Address2: | |||||||||
| City: | TOPPENISH | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098655121 | ||||||||
| FaxNumber: | 5098654333 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2019 | ||||||||
| LastUpdateDate: | 01/23/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CO60274830 | WA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.