Provider Demographics
NPI:1801510631
Name:RAFFERTY, MADELINE C
Entity type:Individual
Prefix:
First Name:MADELINE
Middle Name:C
Last Name:RAFFERTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5835 COLTON BLVD
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94611-2204
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3301 E 12TH ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94601-3424
Practice Address - Country:US
Practice Address - Phone:510-269-9030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-26
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
117851104100000X
CA117851390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No104100000XBehavioral Health & Social Service ProvidersSocial Worker