Healthcare Provider Details

I. General information

NPI: 1356556294
Provider Name (Legal Business Name): AMY MULLERVY LISCW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

390 TOLL GATE RD STE. K 104
WARWICK RI
02886-4326
US

IV. Provider business mailing address

390 TOLL GATE RD STE. K 104
WARWICK RI
02886-4326
US

V. Phone/Fax

Practice location:
  • Phone: 401-739-4969
  • Fax: 401-739-5158
Mailing address:
  • Phone: 401-739-4969
  • Fax: 401-739-5158

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLSW00340
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: