Healthcare Provider Details

I. General information

NPI: 1891437893
Provider Name (Legal Business Name): SAMUEL REILLY DUBOIS LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2022
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 RICHMOND SQ STE 300E
PROVIDENCE RI
02906-5160
US

IV. Provider business mailing address

1 RICHMOND SQ STE 300E
PROVIDENCE RI
02906-5160
US

V. Phone/Fax

Practice location:
  • Phone: 401-785-0040
  • Fax:
Mailing address:
  • Phone: 401-349-3131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW03213
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number000227826
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberISW04823
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: