Healthcare Provider Details

I. General information

NPI: 1992173371
Provider Name (Legal Business Name): PROVIDENCE PARTNERS BEHAVIORAL HEALTHCARE LLP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2015
Last Update Date: 09/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 NEWMAN AVE
RUMFORD RI
02916-1218
US

IV. Provider business mailing address

225 NEWMAN AVE
RUMFORD RI
02916-1218
US

V. Phone/Fax

Practice location:
  • Phone: 401-383-8349
  • Fax: 401-383-8030
Mailing address:
  • Phone: 401-383-8349
  • Fax: 401-383-8030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberISW01147
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDP00312
License Number StateRI
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMHC00156
License Number StateRI
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateRI

VIII. Authorized Official

Name: MS. KAREN MARIE AVERSA
Title or Position: ADMINISTRATIVE MANAGER
Credential:
Phone: 401-383-8349