Provider Demographics
NPI:1790454452
Name:EXCONDE, RAPHAEL LUIS GUTIERREZ (LMSW)
Entity Type:Individual
Prefix:MR
First Name:RAPHAEL LUIS
Middle Name:GUTIERREZ
Last Name:EXCONDE
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1751 2ND AVE STE AZ-5
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128-5363
Mailing Address - Country:US
Mailing Address - Phone:415-818-7270
Mailing Address - Fax:
Practice Address - Street 1:1751 2ND AVE STE AZ-5
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10128-5363
Practice Address - Country:US
Practice Address - Phone:415-818-7270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-07
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY112819104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker