MEDICARE: ROOSEVELT DALE

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
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	CDP01081	RI
2	172V00000X	Community Health Worker	201835	RI

General Provider Information

NPI Number	:	1962375477
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROOSEVELT DALE

Provider Business Mailing Address
First Line	:	806 GREENVILLE AVE
Second Line	:
City	:	JOHNSTON
State	:	RI
Zip	:	02919-1305
Country	:	US
Telephone Number	:	401-516-1314
Fax Number	:

Provider Business Practice Location Address
First Line	:	806 GREENVILLE AVE
Second Line	:
City	:	JOHNSTON
State	:	RI
Zip	:	02919-1305
Country	:	US
Telephone Number	:	401-516-1314
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/29/2025
Last Update Date	:	12/25/2025

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Directions to “ ROOSEVELT DALE ” Practice Location

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