Healthcare Provider Details

I. General information

NPI: 1558508598
Provider Name (Legal Business Name): PROVIDENCE COLLEGE STUDENT HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2009
Last Update Date: 01/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

549 RIVER AVE
PROVIDENCE RI
02918-7000
US

IV. Provider business mailing address

16 VICTORIA LN
MANSFIELD MA
02048-1755
US

V. Phone/Fax

Practice location:
  • Phone: 401-865-2422
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License NumberNPP33985
License Number StateRI

VIII. Authorized Official

Name: CATHERINE KELLEHER
Title or Position: DIRECTOR OF HEALTH SERVICES
Credential: RN
Phone: 401-865-2422