Provider Demographics
NPI:1629262555
Name:RAKIC, ARIATI S (PHD)
Entity Type:Individual
Prefix:
First Name:ARIATI
Middle Name:S
Last Name:RAKIC
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:ARIATI
Other - Middle Name:SUMODJO
Other - Last Name:RAKIC
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:1399 YGNACIO VALLEY RD STE 3
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94598-2868
Mailing Address - Country:US
Mailing Address - Phone:925-389-6723
Mailing Address - Fax:925-320-7275
Practice Address - Street 1:1399 YGNACIO VALLEY RD STE 3
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598-2868
Practice Address - Country:US
Practice Address - Phone:925-389-6723
Practice Address - Fax:925-320-7275
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-04
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY13781103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AU989Medicare PIN