Provider Demographics
NPI:1215981204
Name:RAFFERTY, TERESA M (LICSW, PHD)
Entity type:Individual
Prefix:DR
First Name:TERESA
Middle Name:M
Last Name:RAFFERTY
Suffix:
Gender:F
Credentials:LICSW, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 FOREST ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01609-1729
Mailing Address - Country:US
Mailing Address - Phone:508-752-3009
Mailing Address - Fax:508-791-1195
Practice Address - Street 1:29 FOREST ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01609-1729
Practice Address - Country:US
Practice Address - Phone:508-752-3009
Practice Address - Fax:508-791-1195
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAMA106303101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAPO992OtherBLUE CROSS BLUE SHIELD
MAP22100Medicare ID - Type Unspecified