Healthcare Provider Details

I. General information

NPI: 1396425658
Provider Name (Legal Business Name): EMILY CHRISTIENNE TICEHURST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2023
Last Update Date: 09/21/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 PARK AVE STE 101
CRANSTON RI
02910-3227
US

IV. Provider business mailing address

31 SHERWOOD LN
BARRINGTON RI
02806-1555
US

V. Phone/Fax

Practice location:
  • Phone: 401-497-9115
  • Fax:
Mailing address:
  • Phone: 401-644-9857
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberISW04127
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: