Provider Demographics
NPI:1083042980
Name:RAFFERTY, BRIAN PATRICK
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:PATRICK
Last Name:RAFFERTY
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:PO BOX 671
Mailing Address - Street 2:
Mailing Address - City:FURLONG
Mailing Address - State:PA
Mailing Address - Zip Code:18925-0671
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 E MORELAND RD
Practice Address - Street 2:SUITE A
Practice Address - City:WILLOW GROVE
Practice Address - State:PA
Practice Address - Zip Code:19090-4109
Practice Address - Country:US
Practice Address - Phone:703-447-7406
Practice Address - Fax:267-224-2500
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-31
Last Update Date:2013-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA463274116237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist