Healthcare Provider Details

I. General information

NPI: 1639131360
Provider Name (Legal Business Name): MICHAEL J ELTZ PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2006
Last Update Date: 09/25/2024
Certification Date: 09/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 BROADWAY
PROVIDENCE RI
02909-1102
US

IV. Provider business mailing address

31 KILBURN AVE
LINCOLN RI
02865-2129
US

V. Phone/Fax

Practice location:
  • Phone: 401-714-7440
  • Fax: 401-489-7207
Mailing address:
  • Phone: 401-714-7440
  • Fax: 401-490-2619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPS00748
License Number StateRI
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberPS00748
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: