Healthcare Provider Details

I. General information

NPI: 1700605078
Provider Name (Legal Business Name): BRYANNA ROSE WETHERELL LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2024
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

154 WATERMAN ST STE 3
PROVIDENCE RI
02906-3116
US

IV. Provider business mailing address

79 FOREST ST APT 3
PROVIDENCE RI
02906-2627
US

V. Phone/Fax

Practice location:
  • Phone: 401-655-2225
  • Fax:
Mailing address:
  • Phone: 413-212-6618
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number91987
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMHC02060
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: