Provider Demographics
NPI:1669363214
Name:HERNANDEZ, LILLY TRACEY (R1419440525)
Entity type:Individual
Prefix:
First Name:LILLY
Middle Name:TRACEY
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:R1419440525
Other - Prefix:MS
Other - First Name:LILIA
Other - Middle Name:TRACEY
Other - Last Name:LARA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2330 BEVERLY BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90057-2220
Mailing Address - Country:US
Mailing Address - Phone:213-414-1132
Mailing Address - Fax:213-748-2432
Practice Address - Street 1:2330 BEVERLY BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-2220
Practice Address - Country:US
Practice Address - Phone:213-414-1132
Practice Address - Fax:213-748-2432
Is Sole Proprietor?:No
Enumeration Date:2025-07-11
Last Update Date:2025-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1419440525101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)