Healthcare Provider Details

I. General information

NPI: 1902045834
Provider Name (Legal Business Name): JOE L SMITH LCDP, CCJP, CAS, RCS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2009
Last Update Date: 02/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 ELMWOOD AVE
WARWICK RI
02888-2404
US

IV. Provider business mailing address

2020 ELMWOOD AVE
WARWICK RI
02888-2404
US

V. Phone/Fax

Practice location:
  • Phone: 401-781-2700
  • Fax: 401-781-2790
Mailing address:
  • Phone: 401-781-2700
  • Fax: 401-781-2790

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCDP00081
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: