Provider Demographics
NPI:1720625601
Name:RAFFERTY, SHANE (MS, CCLS)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:RAFFERTY
Suffix:
Gender:M
Credentials:MS, CCLS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4852 N ROCKWELL ST APT 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-6521
Mailing Address - Country:US
Mailing Address - Phone:847-219-1824
Mailing Address - Fax:
Practice Address - Street 1:4852 N ROCKWELL ST APT 2
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-6521
Practice Address - Country:US
Practice Address - Phone:847-219-1824
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-10
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL213122080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics