Provider Demographics
NPI:1285736298
Name:RAFTERY, JOHN P (EDD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:P
Last Name:RAFTERY
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 WHITCOMB AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02130
Mailing Address - Country:US
Mailing Address - Phone:617-524-3070
Mailing Address - Fax:617-327-9594
Practice Address - Street 1:116 WHITCOMB AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02130
Practice Address - Country:US
Practice Address - Phone:617-524-3070
Practice Address - Fax:617-327-9594
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA124103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1852256Medicaid
1892002OtherMA-BEH-HEALTH
MAW01464Medicare ID - Type Unspecified