Healthcare Provider Details

I. General information

NPI: 1972651552
Provider Name (Legal Business Name): JENNIFER DIANE RYALL LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JENNIFER DIANE FRAGALE

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 05/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1087 WARWICK AVE
WARWICK RI
02888-3545
US

IV. Provider business mailing address

212 GLENWOOD AVE
PAWTUCKET RI
02860-5939
US

V. Phone/Fax

Practice location:
  • Phone: 401-461-6676
  • Fax: 401-461-3165
Mailing address:
  • Phone: 401-461-6676
  • Fax: 401-461-3165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberISW01803
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: