Provider Demographics
NPI:1336900653
Name:GAINES, RAPHAEL
Entity type:Individual
Prefix:
First Name:RAPHAEL
Middle Name:
Last Name:GAINES
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1840 PARKVIEW CT NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152-4775
Mailing Address - Country:US
Mailing Address - Phone:229-894-2430
Mailing Address - Fax:
Practice Address - Street 1:94-428 MOKUOLA ST STE 214A
Practice Address - Street 2:
Practice Address - City:WAIPAHU
Practice Address - State:HI
Practice Address - Zip Code:96797-3396
Practice Address - Country:US
Practice Address - Phone:229-894-2430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-23
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
GARBT-24-320720106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician