Provider Demographics
NPI:1437975067
Name:RAPHAEL, CULLEN
Entity type:Individual
Prefix:
First Name:CULLEN
Middle Name:
Last Name:RAPHAEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4322 SE YAMHILL ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97215-2460
Mailing Address - Country:US
Mailing Address - Phone:503-660-7331
Mailing Address - Fax:
Practice Address - Street 1:1200 CONCORD AVE STE 185
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-5006
Practice Address - Country:US
Practice Address - Phone:503-660-7331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-27
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician