Healthcare Provider Details

I. General information

NPI: 1841209210
Provider Name (Legal Business Name): NANCY CAROL HETHERINGTON LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 07/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 WAYLAND AVE SUITE 1
PROVIDENCE RI
02906-4318
US

IV. Provider business mailing address

120 WAYLAND AVE SUITE 1
PROVIDENCE RI
02906-4318
US

V. Phone/Fax

Practice location:
  • Phone: 401-709-9497
  • Fax: 401-709-3776
Mailing address:
  • Phone: 401-709-9497
  • Fax: 401-709-3776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberISW01151
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: