Healthcare Provider Details

I. General information

NPI: 1962024869
Provider Name (Legal Business Name): CHONLADA JARUKITISAKUL PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2020
Last Update Date: 08/28/2025
Certification Date: 08/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 BROOK STREET
PROVIDENCE RI
02906
US

IV. Provider business mailing address

69 BROWN STREET BOX 1960
PROVIDENCE RI
02912-0001
US

V. Phone/Fax

Practice location:
  • Phone: 401-863-3476
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number11069-PY-PR
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPS01791
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: