Healthcare Provider Details

I. General information

NPI: 1003972084
Provider Name (Legal Business Name): SILVER FERN PRACTICE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 11/06/2025
Certification Date: 11/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

545 PAWTUCKET AVE MAILBOX 402
PAWTUCKET RI
02860-6046
US

IV. Provider business mailing address

4 RICHMOND SQ STE 200
PROVIDENCE RI
02906-5117
US

V. Phone/Fax

Practice location:
  • Phone: 401-475-5775
  • Fax:
Mailing address:
  • Phone: 401-433-4172
  • Fax: 401-433-0612

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: MICHELLE MONIZ
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 401-433-4172