Healthcare Provider Details

I. General information

NPI: 1205112422
Provider Name (Legal Business Name): ANN FUNICELLO LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2011
Last Update Date: 11/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

54 WOOD COVE DR
COVENTRY RI
02816-6606
US

IV. Provider business mailing address

54 WOOD COVE DR
COVENTRY RI
02816-6606
US

V. Phone/Fax

Practice location:
  • Phone: 401-822-0274
  • Fax:
Mailing address:
  • Phone: 401-822-0274
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberISW0063
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number054450
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: