Provider Demographics
NPI:1922143627
Name:RAFTERY, ROGER THOMAS (PHD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:THOMAS
Last Name:RAFTERY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2130 HIGHWAY 35
Mailing Address - Street 2:BLDG. A SUITE 114
Mailing Address - City:SEA GIRT
Mailing Address - State:NJ
Mailing Address - Zip Code:08750-1010
Mailing Address - Country:US
Mailing Address - Phone:732-449-7800
Mailing Address - Fax:732-449-7803
Practice Address - Street 1:2130 HIGHWAY 35
Practice Address - Street 2:BLDG A SUITE 114
Practice Address - City:SEA GIRT
Practice Address - State:NJ
Practice Address - Zip Code:08750-1010
Practice Address - Country:US
Practice Address - Phone:732-449-7800
Practice Address - Fax:732-449-7803
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ2570103TC0700X, 103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ594945Medicare ID - Type Unspecified