Provider Demographics
NPI:1114412657
Name:RAPHAEL, ANDREA (OT)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:RAPHAEL
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 CHATEAU SQ
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14618-5131
Mailing Address - Country:US
Mailing Address - Phone:585-813-5455
Mailing Address - Fax:
Practice Address - Street 1:4646 FAIRPORT NINE MILE PT RD
Practice Address - Street 2:
Practice Address - City:FAIRPORT
Practice Address - State:NY
Practice Address - Zip Code:14450-1163
Practice Address - Country:US
Practice Address - Phone:585-377-0350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-27
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP10746225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist