Provider Demographics
NPI:1346206067
Name:RAFFERTY, JAMES (PHD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:RAFFERTY
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 1144
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45401-1144
Mailing Address - Country:US
Mailing Address - Phone:937-259-9900
Mailing Address - Fax:937-259-9999
Practice Address - Street 1:128 APPLE STREET
Practice Address - Street 2:CHE #1820
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409
Practice Address - Country:US
Practice Address - Phone:937-208-6359
Practice Address - Fax:937-341-8266
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3324103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0606697Medicaid
OH0606697Medicaid