Healthcare Provider Details

I. General information

NPI: 1093662363
Provider Name (Legal Business Name): X
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2026
Last Update Date: 03/14/2026
Certification Date: 03/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 WOODLAWN AVE
NORTH PROVIDENCE RI
02911-1504
US

IV. Provider business mailing address

5 WOODLAWN AVE
NORTH PROVIDENCE RI
02911-1504
US

V. Phone/Fax

Practice location:
  • Phone: 401-263-7397
  • Fax:
Mailing address:
  • Phone: 401-263-7397
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. GABRIELLE X
Title or Position: OWNER
Credential:
Phone: 401-262-7397