Basic Information
| Provider Information | |||||||||
| NPI: | 1376014506 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RAFTERY RAMIREZ | ||||||||
| FirstName: | MARYCILENE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MSC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RAFTERY RAMIREZ | ||||||||
| OtherFirstName: | MARYCILENE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | 101Y00000X | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4 CANAL PARK PH 2 | ||||||||
| Address2: | |||||||||
| City: | CAMBRIDGE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021412207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6178007005 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 14 FORDHAM RD | ||||||||
| Address2: | |||||||||
| City: | ALLSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021343006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176205894 | ||||||||
| FaxNumber: | 6177826444 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2018 | ||||||||
| LastUpdateDate: | 12/16/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.