Provider Demographics
NPI:1174695712
Name:RACKLEY, CHRISTINE ALICE (PSYD)
Entity type:Individual
Prefix:DR
First Name:CHRISTINE
Middle Name:ALICE
Last Name:RACKLEY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1018 SHEAR RD
Mailing Address - Street 2:
Mailing Address - City:MASONVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13804
Mailing Address - Country:US
Mailing Address - Phone:607-467-2027
Mailing Address - Fax:
Practice Address - Street 1:1018 SHEAR RD
Practice Address - Street 2:
Practice Address - City:MASONVILLE
Practice Address - State:NY
Practice Address - Zip Code:13804
Practice Address - Country:US
Practice Address - Phone:607-467-2027
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2014-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY13462-1103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYV82471Medicare ID - Type Unspecified