Provider Demographics
NPI:1720295447
Name:RAPHAEL, EMILIE ROSS (PHD)
Entity Type:Individual
Prefix:DR
First Name:EMILIE
Middle Name:ROSS
Last Name:RAPHAEL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:EMILIE
Other - Middle Name:ROSS
Other - Last Name:LAIRD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:46 DIANA DEL SILVA CT
Mailing Address - Street 2:
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27516-8692
Mailing Address - Country:US
Mailing Address - Phone:919-932-7727
Mailing Address - Fax:
Practice Address - Street 1:251A CEDAR LAKE RD
Practice Address - Street 2:THE LAKE HOUSE
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27516-9544
Practice Address - Country:US
Practice Address - Phone:919-932-7727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2007-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD420707-01103T00000X
NCPP2335103TB0200X
103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC11336532OtherCAQH NUMBER
MD35090OtherNATIONAL REGISTER NUMBER
NCPP2335OtherLICENSE NUMBER