Healthcare Provider Details

I. General information

NPI: 1811162316
Provider Name (Legal Business Name): BROADWAY PSYCHOTHERAPY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2008
Last Update Date: 05/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

347 BROADWAY
PROVIDENCE RI
02909-1101
US

IV. Provider business mailing address

347 BROADWAY
PROVIDENCE RI
02909-1101
US

V. Phone/Fax

Practice location:
  • Phone: 401-270-9808
  • Fax: 401-354-7455
Mailing address:
  • Phone: 401-270-9808
  • Fax: 401-354-7455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS00585
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberISW00174
License Number StateRI

VIII. Authorized Official

Name: DR. JEFFREY P. MIGNEAULT
Title or Position: PRESIDENT
Credential: PH.D.
Phone: 401-270-9808