Healthcare Provider Details

I. General information

NPI: 1699717488
Provider Name (Legal Business Name): WILLIAM JIACOVELLI LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 04/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 VETERANS MEMORIAL PKWY
RIVERSIDE RI
02915-5061
US

IV. Provider business mailing address

1011 VETERANS MEMORIAL PKWY
RIVERSIDE RI
02915-5061
US

V. Phone/Fax

Practice location:
  • Phone: 401-432-1000
  • Fax: 401-432-1500
Mailing address:
  • Phone: 401-432-1000
  • Fax: 401-432-1500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberISW01681
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: