=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215207105
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KARYNE B WILNER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/09/2012
-----------------------------------------------------
Last Update Date | 01/09/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 182 BUTLER AVE
-----------------------------------------------------
City | PROVIDENCE
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02906-5317
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-316-7041
-----------------------------------------------------
Fax | 401-751-8997
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 116 GIDEON LAWTON LN
-----------------------------------------------------
City | PORTSMOUTH
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02871-4049
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-316-7041
-----------------------------------------------------
Fax | 401-751-8997
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | DR. KARYNE B WILNER
-----------------------------------------------------
Credential | PSYD
-----------------------------------------------------
Telephone | 401-316-7041
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PS00923
-----------------------------------------------------
License Number State | RI
-----------------------------------------------------