Healthcare Provider Details

I. General information

NPI: 1366112740
Provider Name (Legal Business Name): NATOYA BERNICE LEBED
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2021
Last Update Date: 09/16/2021
Certification Date: 09/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3044 PAWTUCKET AVE
RIVERSIDE RI
02915-5050
US

IV. Provider business mailing address

3044 PAWTUCKET AVE
RIVERSIDE RI
02915-5050
US

V. Phone/Fax

Practice location:
  • Phone: 401-489-5304
  • Fax: 401-461-9194
Mailing address:
  • Phone: 401-489-5304
  • Fax: 401-461-9194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1174521488
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: