Provider Demographics
NPI:1366503906
Name:MORA DE JESUS, RAFAEL (PHD)
Entity Type:Individual
Prefix:DR
First Name:RAFAEL
Middle Name:
Last Name:MORA DE JESUS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:RAFAEL
Other - Middle Name:
Other - Last Name:MORA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:210 WETHERSFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06114-1113
Mailing Address - Country:US
Mailing Address - Phone:860-296-0094
Mailing Address - Fax:860-206-1184
Practice Address - Street 1:210 WETHERSFIELD AVE
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06114-1113
Practice Address - Country:US
Practice Address - Phone:860-296-0094
Practice Address - Fax:860-206-1184
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001877103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004132700Medicaid
CT680001341Medicare ID - Type Unspecified