Healthcare Provider Details

I. General information

NPI: 1427087782
Provider Name (Legal Business Name): ROBERT JAMES BROTHERS LCDP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 03/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2198 WALLUM LAKE RD
PASCOAG RI
02859
US

IV. Provider business mailing address

528 N MAIN ST
PROVIDENCE RI
02904-5757
US

V. Phone/Fax

Practice location:
  • Phone: 401-568-6670
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCDP00115
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: