Provider Demographics
NPI:1366950297
Name:RAFAEL, JUAN JOSE JR (RBT-18-59188)
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:JOSE
Last Name:RAFAEL
Suffix:JR
Gender:M
Credentials:RBT-18-59188
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2973 HARBOR BLVD # 136
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-3912
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1063 MCGAW AVE STE 100
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92614-5554
Practice Address - Country:US
Practice Address - Phone:714-834-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-12
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-18-59188106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician