Healthcare Provider Details

I. General information

NPI: 1427364736
Provider Name (Legal Business Name): ROBERTA L TVENSTRUP LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2010
Last Update Date: 08/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 FAIRVIEW AVE
COVENTRY RI
02816-7504
US

IV. Provider business mailing address

21 AUDUBON LN
HOPE RI
02831-1628
US

V. Phone/Fax

Practice location:
  • Phone: 401-486-7960
  • Fax: 401-826-1858
Mailing address:
  • Phone: 401-486-7960
  • Fax: 401-826-1858

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberISW01155
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: