Provider Demographics
NPI:1568919991
Name:RAPHAEL, FARATH
Entity Type:Individual
Prefix:
First Name:FARATH
Middle Name:
Last Name:RAPHAEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 LIBERTY AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11703-5404
Mailing Address - Country:US
Mailing Address - Phone:631-404-0143
Mailing Address - Fax:
Practice Address - Street 1:130 LIBERTY
Practice Address - Street 2:
Practice Address - City:NORTH BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11703
Practice Address - Country:US
Practice Address - Phone:631-404-0143
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst