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NPI Code Detail

MEDICARE: HOME PORT THERAPY

MEDICARE: HOME PORT THERAPY
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1261QM0850XAdult Mental Health Clinic/CenterMFT00100RI

General Provider Information

NPI Number : 1740460872
Entity Type Code : Organization
Provider Name (Legal Business Name) : HOME PORT THERAPY
Provider Business Mailing Address
First Line : 23 NORTH RD STE A25
Second Line :
City : PEACE DALE
State : RI
Zip : 02879-2176
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 23 NORTH RD STE A25
Second Line :
City : PEACE DALE
State : RI
Zip : 02879-2176
Country : US
Telephone Number : 401-932-1181
Fax Number : 401-783-1154
Authorized Official
Title or Position : OWNER
Name : MR. REYNARD BULLOCK
Credential : MS LMFT
Telephone Number : 401-932-1181
Provider Enumeration Date : 11/06/2007
Last Update Date : 11/06/2007

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Directions to “HOME PORT THERAPY ” Practice Location

Language Start Address Practice Location
These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

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