Provider Demographics
NPI:1972067023
Name:HERNANDEZ, RAYMOND (CO60274830)
Entity type:Individual
Prefix:
First Name:RAYMOND
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:CO60274830
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 367
Mailing Address - Street 2:
Mailing Address - City:TOPPENISH
Mailing Address - State:WA
Mailing Address - Zip Code:98948-0367
Mailing Address - Country:US
Mailing Address - Phone:509-865-5121
Mailing Address - Fax:509-865-4333
Practice Address - Street 1:20 GUNNYON RD.
Practice Address - Street 2:
Practice Address - City:TOPPENISH
Practice Address - State:WA
Practice Address - Zip Code:98948
Practice Address - Country:US
Practice Address - Phone:509-865-5121
Practice Address - Fax:509-865-4333
Is Sole Proprietor?:No
Enumeration Date:2019-01-23
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60274830101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)