Provider Demographics
NPI:1780856732
Name:RAFFERTY, MARTHA (LISW)
Entity Type:Individual
Prefix:MS
First Name:MARTHA
Middle Name:
Last Name:RAFFERTY
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 ACAPULCO RD NE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87144-6449
Mailing Address - Country:US
Mailing Address - Phone:505-991-0443
Mailing Address - Fax:505-896-3510
Practice Address - Street 1:1350 ACAPULCO RD NE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87144-6449
Practice Address - Country:US
Practice Address - Phone:505-991-0443
Practice Address - Fax:505-896-3510
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-31
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-06715101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM46572341Medicaid