Provider Demographics
NPI:1164457933
Name:CALDERON, RAFAEL (MFT)
Entity Type:Individual
Prefix:MR
First Name:RAFAEL
Middle Name:
Last Name:CALDERON
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 N LOUISE ST
Mailing Address - Street 2:APT 312
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91206-2044
Mailing Address - Country:US
Mailing Address - Phone:818-244-8623
Mailing Address - Fax:
Practice Address - Street 1:8700 RESEDA AVE BLVD
Practice Address - Street 2:STE. 209
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91324
Practice Address - Country:US
Practice Address - Phone:818-772-9981
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 40703106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist