Provider Demographics
NPI:1932968989
Name:RAFANAN, TOM R
Entity Type:Individual
Prefix:
First Name:TOM
Middle Name:R
Last Name:RAFANAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:TOM CLEMEN
Other - Middle Name:R
Other - Last Name:RAFANAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5075 SHOREHAM PL STE 115
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92122-5927
Mailing Address - Country:US
Mailing Address - Phone:858-272-2662
Mailing Address - Fax:
Practice Address - Street 1:5075 SHOREHAM PL STE 115
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92122-5927
Practice Address - Country:US
Practice Address - Phone:858-272-2662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-13
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24-326877106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician