Provider Demographics
NPI:1750827788
Name:FAZAL, RAFFAT
Entity Type:Individual
Prefix:MRS
First Name:RAFFAT
Middle Name:
Last Name:FAZAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:482 BARLOW AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10308-1205
Mailing Address - Country:US
Mailing Address - Phone:917-584-6507
Mailing Address - Fax:
Practice Address - Street 1:2291 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-6625
Practice Address - Country:US
Practice Address - Phone:917-584-6507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-14
Last Update Date:2017-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003079101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health