Provider Demographics
NPI:1598070476
Name:RAFACZ, JEREMY EDWARD (MA, BCBA, LBA)
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:EDWARD
Last Name:RAFACZ
Suffix:
Gender:M
Credentials:MA, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 S 35TH ST
Mailing Address - Street 2:
Mailing Address - City:GALESBURG
Mailing Address - State:MI
Mailing Address - Zip Code:49053-9688
Mailing Address - Country:US
Mailing Address - Phone:269-250-8200
Mailing Address - Fax:
Practice Address - Street 1:1800 S 35TH ST
Practice Address - Street 2:
Practice Address - City:GALESBURG
Practice Address - State:MI
Practice Address - Zip Code:49053-9688
Practice Address - Country:US
Practice Address - Phone:269-250-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-16
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7401001819103K00000X
222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist