Healthcare Provider Details

I. General information

NPI: 1225820442
Provider Name (Legal Business Name): BRAINWISE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2025
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1275 WAMPANOAG TRL STE 9
RIVERSIDE RI
02915-1217
US

IV. Provider business mailing address

1275 WAMPANOAG TRL STE 9
RIVERSIDE RI
02915-1217
US

V. Phone/Fax

Practice location:
  • Phone: 401-352-8440
  • Fax:
Mailing address:
  • Phone: 401-352-8440
  • Fax: 401-355-3655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State

VIII. Authorized Official

Name: ASHLEY LETENDRE
Title or Position: BILLER
Credential:
Phone: 401-812-5134