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General NPI Number Information
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NPI Number | 1720625601
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Entity Type | Individual
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Provider Name | SHANE RAFFERTY MS, CCLS
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Gender | Male
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Dates
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Enumeration Date | 12/10/2019
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Last Update Date | 06/03/2020
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Provider Practice Location Address
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Address Line | 4852 N ROCKWELL ST APT 2
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City | CHICAGO
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State | IL
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Zip | 60625-6521
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Country | US
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Telephone | 847-219-1824
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Fax |
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Provider Business Mailing Address
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Address Line | 4852 N ROCKWELL ST APT 2
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City | CHICAGO
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State | IL
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Zip | 60625-6521
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Country | US
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Telephone | 847-219-1824
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2080P0006X
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Taxonomy Name | Developmental - Behavioral Pediatrics Physician
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License Number | 21312
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License Number State | IL
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