Provider Demographics
NPI:1598420861
Name:RAFFAELE-ILIC, NANCY (MA, LPCC)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:RAFFAELE-ILIC
Suffix:
Gender:F
Credentials:MA, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 JENKINS RANCH RD UNIT C
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-9451
Mailing Address - Country:US
Mailing Address - Phone:970-799-2202
Mailing Address - Fax:
Practice Address - Street 1:1911 MAIN AVE STE 246
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-5077
Practice Address - Country:US
Practice Address - Phone:970-799-2202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-02
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0018628101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health