Healthcare Provider Details

I. General information

NPI: 1053766733
Provider Name (Legal Business Name): KAYLA MOURATO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2016
Last Update Date: 08/02/2022
Certification Date: 10/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 NEWMAN AVE
RUMFORD RI
02916-1218
US

IV. Provider business mailing address

10 MEADOWBROOK RD
BROCKTON MA
02301-7122
US

V. Phone/Fax

Practice location:
  • Phone: 508-838-9606
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberLBA00278
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: