Healthcare Provider Details

I. General information

NPI: 1467875633
Provider Name (Legal Business Name): BRIAN MULLERVY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2014
Last Update Date: 01/10/2022
Certification Date: 01/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 BACON ST
PAWTUCKET RI
02860-5542
US

IV. Provider business mailing address

101 BACON ST
PAWTUCKET RI
02860-5542
US

V. Phone/Fax

Practice location:
  • Phone: 401-724-8400
  • Fax: 401-722-5280
Mailing address:
  • Phone: 401-724-8400
  • Fax: 401-722-5280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW02074
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: