Provider Demographics
NPI:1710273206
Name:RAFFAELE, KELLY D (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:D
Last Name:RAFFAELE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 JOHN ST
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-7350
Mailing Address - Country:US
Mailing Address - Phone:516-987-4548
Mailing Address - Fax:
Practice Address - Street 1:15 JOHN ST
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-7350
Practice Address - Country:US
Practice Address - Phone:516-987-4548
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-22
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
196982926104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker