Provider Demographics
NPI:1538174446
Name:RAPHAEL, AMY JILL (PHD)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:JILL
Last Name:RAPHAEL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:631 W END AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10024-1034
Mailing Address - Country:US
Mailing Address - Phone:212-724-3035
Mailing Address - Fax:914-693-2981
Practice Address - Street 1:631 W END AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-1034
Practice Address - Country:US
Practice Address - Phone:212-724-3035
Practice Address - Fax:914-693-2981
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-29
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010241103T00000X, 103TA0700X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01515553Medicaid
NY01515553Medicaid