Healthcare Provider Details

I. General information

NPI: 1952651895
Provider Name (Legal Business Name): CHILDREN IN BALANCE PSYCHOLOGICAL ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2012
Last Update Date: 04/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

575 E MAIN RD 4
MIDDLETOWN RI
02842-5528
US

IV. Provider business mailing address

P.O. BOX 577
SOMERSET MA
02726
US

V. Phone/Fax

Practice location:
  • Phone: 508-962-7364
  • Fax: 401-619-7766
Mailing address:
  • Phone: 508-962-7364
  • Fax: 401-619-7766

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number00547
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6722
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number7566
License Number StateMA
# 4
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number7566
License Number StateRI
# 5
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW01724
License Number StateRI
# 6
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number02472
License Number StateRI
# 7
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberMHC00502
License Number StateRI
# 8
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number7566
License Number StateMA

VIII. Authorized Official

Name: MISS TIFFANY BOURQUIN
Title or Position: CEO/EXECUTIVE DIRECTOR
Credential: LMHC
Phone: 508-962-7364