Healthcare Provider Details

I. General information

NPI: 1053907428
Provider Name (Legal Business Name): SVETLANA GORETAYA LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2020
Last Update Date: 11/30/2023
Certification Date: 11/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 SOUTH COUNTY COMMONS WAY 2ND FLOOR, SUITE D8-1
WAKEFIELD RI
02879
US

IV. Provider business mailing address

3495 POST RD APT 106
WARWICK RI
02886-7116
US

V. Phone/Fax

Practice location:
  • Phone: 401-282-9221
  • Fax:
Mailing address:
  • Phone: 401-282-9221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberISW03644
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW02250
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: