Provider Demographics
NPI:1922100825
Name:RAFTERY, DESMOND PAUL (LCSW)
Entity Type:Individual
Prefix:MR
First Name:DESMOND
Middle Name:PAUL
Last Name:RAFTERY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:787 PENRITH AVE
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE VILLAGE
Mailing Address - State:IL
Mailing Address - Zip Code:60007-3612
Mailing Address - Country:US
Mailing Address - Phone:630-415-3638
Mailing Address - Fax:
Practice Address - Street 1:787 PENRITH AVE
Practice Address - Street 2:
Practice Address - City:ELK GROVE VILLAGE
Practice Address - State:IL
Practice Address - Zip Code:60007-3612
Practice Address - Country:US
Practice Address - Phone:630-415-3638
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.008719101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1626558OtherBLUE CROSS BLUE SHIELD
IL1626558OtherBLUE CROSS BLUE SHIELD