Basic Information
| Provider Information | |||||||||
| NPI: | 1477636702 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RAFFERTY | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | |||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 784 | ||||||||
| Address2: | |||||||||
| City: | WATERTOWN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024710784 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 169 ELM STREET | ||||||||
| Address2: | |||||||||
| City: | WALTHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024535356 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7818948440 | ||||||||
| FaxNumber: | 7818941202 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 2029046 | MA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1004745 | 01 | MA | NHP | OTHER | 1303287 | 01 | MA | MBHP | OTHER | M18633 | 01 | MA | BCBS | OTHER | 1303287 | 05 | MA | MEDICAID | NP01332 | 01 | BOSTON MEDICAL | OTHER | 703136 | 01 | MA | TUFTS | OTHER | 99618201 | 01 | MA | NETWORK HEALTH | OTHER |