Healthcare Provider Details

I. General information

NPI: 1164616371
Provider Name (Legal Business Name): GHAZALEH RAFATI PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2007
Last Update Date: 08/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3301 E 12TH ST STE 259
OAKLAND CA
94601-2940
US

IV. Provider business mailing address

5416 BARRETT AVE
EL CERRITO CA
94530-1404
US

V. Phone/Fax

Practice location:
  • Phone: 510-269-9030
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY20555
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: