Healthcare Provider Details

I. General information

NPI: 1619078045
Provider Name (Legal Business Name): PAULINE B WHEELER LCDP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 CENTERVILLE RD
WARWICK RI
02886-0200
US

IV. Provider business mailing address

7 LANSING AVE
WARWICK RI
02888-2661
US

V. Phone/Fax

Practice location:
  • Phone: 401-732-5656
  • Fax: 401-738-8634
Mailing address:
  • Phone: 401-467-5435
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCDP 00000262
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: