Provider Demographics
NPI:1902180177
Name:FEDEBAGHA, RAQUEL (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:RAQUEL
Middle Name:
Last Name:FEDEBAGHA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 E MOSHOLU PKWY N
Mailing Address - Street 2:4A
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-2904
Mailing Address - Country:US
Mailing Address - Phone:646-571-6492
Mailing Address - Fax:
Practice Address - Street 1:1 FORDHAM PLZ
Practice Address - Street 2:5 FL
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10458-5871
Practice Address - Country:US
Practice Address - Phone:929-220-8425
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-05
Last Update Date:2016-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY084538-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical