Healthcare Provider Details

I. General information

NPI: 1245881002
Provider Name (Legal Business Name): KATELYN AFFLECK PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2019
Last Update Date: 09/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 VETERANS MEMORIAL PKWY
RIVERSIDE RI
02915-5099
US

IV. Provider business mailing address

117 ELLENFIELD ST STE 101
PROVIDENCE RI
02905-4541
US

V. Phone/Fax

Practice location:
  • Phone: 401-432-1418
  • Fax:
Mailing address:
  • Phone: 401-444-6779
  • Fax: 401-444-6912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPS01811
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: