Healthcare Provider Details

I. General information

NPI: 1245617422
Provider Name (Legal Business Name): WHITESTONE LIFE CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2015
Last Update Date: 04/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 CRANSTON ST
PROVIDENCE RI
02907-2744
US

IV. Provider business mailing address

475 CRANSTON ST
PROVIDENCE RI
02907-2744
US

V. Phone/Fax

Practice location:
  • Phone: 401-523-7520
  • Fax:
Mailing address:
  • Phone: 401-523-7520
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name: HERMAN J FALU JR.
Title or Position: SUBSTANCE ABUSE THERAPIST
Credential: LCDP LCDS
Phone: 401-523-7520