Healthcare Provider Details

I. General information

NPI: 1780709436
Provider Name (Legal Business Name): RAPHAEL ROMERO PSY.D.,
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 07/19/2023
Certification Date: 07/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 W HILL BLVD
CHARLESTON SC
29404-4704
US

IV. Provider business mailing address

204 W HILL BLVD
CHARLESTON SC
29404-4704
US

V. Phone/Fax

Practice location:
  • Phone: 843-963-6539
  • Fax:
Mailing address:
  • Phone: 843-963-6539
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY24863
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: