Provider Demographics
NPI:1699417592
Name:HERNANDEZ, RAFAEL LUIS
Entity type:Individual
Prefix:
First Name:RAFAEL
Middle Name:LUIS
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:RAFAEL
Other - Middle Name:LUIS
Other - Last Name:CASTANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1041 GRAND AVE # 302
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55105-3002
Mailing Address - Country:US
Mailing Address - Phone:952-767-2267
Mailing Address - Fax:
Practice Address - Street 1:1801 AMERICAN BLVD E STE 8
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55425-1230
Practice Address - Country:US
Practice Address - Phone:952-767-2267
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-11
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician