Healthcare Provider Details

I. General information

NPI: 1497597991
Provider Name (Legal Business Name): KEVIN FREDERICK LIPPE JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2024
Last Update Date: 06/07/2024
Certification Date: 06/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3045 TOWER HILL RD
SAUNDERSTOWN RI
02874-1501
US

IV. Provider business mailing address

29 WALNUT ST
EAST PROVIDENCE RI
02914-4425
US

V. Phone/Fax

Practice location:
  • Phone: 401-789-0934
  • Fax:
Mailing address:
  • Phone: 401-527-0174
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: