Healthcare Provider Details

I. General information

NPI: 1548562655
Provider Name (Legal Business Name): KEITH BERUBE CAGS LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/22/2010
Last Update Date: 03/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47A CEDAR SWAMP RD
SMITHFIELD RI
02917
US

IV. Provider business mailing address

47A CEDAR SWAMP RD
SMITHFIELD RI
02917-2431
US

V. Phone/Fax

Practice location:
  • Phone: 401-768-3600
  • Fax:
Mailing address:
  • Phone: 401-768-3600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberMHC00473
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMHC00473
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: