Healthcare Provider Details

I. General information

NPI: 1316786668
Provider Name (Legal Business Name): ANASTACIA Y. KUDINOVA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2024
Last Update Date: 06/14/2024
Certification Date: 06/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HOPPIN ST
PROVIDENCE RI
02903-4141
US

IV. Provider business mailing address

117 ELLENFIELD ST STE 101
PROVIDENCE RI
02905-4541
US

V. Phone/Fax

Practice location:
  • Phone: 401-444-8945
  • Fax: 401-444-8742
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS02153
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPS02153
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: