Healthcare Provider Details

I. General information

NPI: 1801730742
Provider Name (Legal Business Name): MADDI R GERVASIO-PONTARELLI PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2026
Last Update Date: 04/20/2026
Certification Date: 04/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 VETERANS MEMORIAL PKWY
RIVERSIDE RI
02915-5099
US

IV. Provider business mailing address

1011 VETERANS MEMORIAL PKWY
RIVERSIDE RI
02915-5099
US

V. Phone/Fax

Practice location:
  • Phone: 401-432-1022
  • Fax:
Mailing address:
  • Phone: 401-432-1022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: