Healthcare Provider Details

I. General information

NPI: 1790662732
Provider Name (Legal Business Name): EAST BAY PSYCHOLOGICAL SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2025
Last Update Date: 10/09/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

331 WATERMAN STREET 1 RICHMOND SQ STE 130C
PROVIDENCE RI
02906-5155
US

IV. Provider business mailing address

331 WATERMAN STREET 1 RICHMOND SQ STE 130C
PROVIDENCE RI
02906-5155
US

V. Phone/Fax

Practice location:
  • Phone: 914-427-5640
  • Fax:
Mailing address:
  • Phone: 914-427-5640
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. MARK E. KILMER
Title or Position: OWNER
Credential: PHD
Phone: 914-427-5640