Provider Demographics
NPI:1588200984
Name:RAPHA PROVIDER AGENCY LLC
Entity Type:Organization
Organization Name:RAPHA PROVIDER AGENCY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/BSC
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:H
Authorized Official - Last Name:WEATHERS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:575-770-7139
Mailing Address - Street 1:1215 GUSDORF RD STE A
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-6914
Mailing Address - Country:US
Mailing Address - Phone:575-770-7139
Mailing Address - Fax:
Practice Address - Street 1:1215 GUSDORF RD STE A
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-6914
Practice Address - Country:US
Practice Address - Phone:575-770-7139
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-20
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty