Healthcare Provider Details

I. General information

NPI: 1043435191
Provider Name (Legal Business Name): DIANE ELIZABETH PASSANTINO LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2007
Last Update Date: 04/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 DOVER AVE
EAST PROVIDENCE RI
02914-1801
US

IV. Provider business mailing address

55 DOVER AVE
EAST PROVIDENCE RI
02914
US

V. Phone/Fax

Practice location:
  • Phone: 401-248-5823
  • Fax: 401-406-2701
Mailing address:
  • Phone: 401-248-5823
  • Fax: 401-406-2701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberISWO1755
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: