Provider Demographics
NPI:1326108648
Name:RAQUE, DAVID (PHD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:RAQUE
Suffix:
Gender:M
Credentials:PHD
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 429
Mailing Address - Street 2:
Mailing Address - City:MINERAL BLUFF
Mailing Address - State:GA
Mailing Address - Zip Code:30559-0429
Mailing Address - Country:US
Mailing Address - Phone:706-455-2492
Mailing Address - Fax:704-492-5714
Practice Address - Street 1:11B LENOX POINTE NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30324-3171
Practice Address - Country:US
Practice Address - Phone:706-455-2492
Practice Address - Fax:706-492-5714
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY000413103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPSY000413OtherLICENSE NUMBER