Provider Demographics
NPI:1932594454
Name:LOFTUS, RACHEL
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:
Last Name:LOFTUS
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 1:390 BLACK MEADOW RD
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:10918-2222
Mailing Address - Country:US
Mailing Address - Phone:845-421-0341
Mailing Address - Fax:
Practice Address - Street 1:390 BLACK MEADOW RD
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:NY
Practice Address - Zip Code:10918-2222
Practice Address - Country:US
Practice Address - Phone:845-421-0341
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-01
Last Update Date:2015-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000572-1103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1-14-9574OtherBCBA CERTIFICATION NUMBER
NY000572-1OtherSTATE LICENSE NUMBER
NY8801582OtherSTATE CERTIFICATE NUMBER