Provider Demographics
NPI:1093562779
Name:RAFTERY, KAITLIN MACKENZIE (MAAT, PLPC, ATR)
Entity type:Individual
Prefix:
First Name:KAITLIN
Middle Name:MACKENZIE
Last Name:RAFTERY
Suffix:
Gender:F
Credentials:MAAT, PLPC, ATR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 SAINT PETERS CENTRE BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-1653
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:150 SAINT PETERS CENTRE BLVD STE B
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-1653
Practice Address - Country:US
Practice Address - Phone:636-345-4744
Practice Address - Fax:636-244-1171
Is Sole Proprietor?:No
Enumeration Date:2024-05-01
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022050165101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional