=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295458784
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RHODE ISLAND LYMPHEDEMA THERAPY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2022
-----------------------------------------------------
Last Update Date | 09/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4 COVENTRY SHOPPERS PARK
-----------------------------------------------------
City | COVENTRY
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02816-5702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-368-4263
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 107 BAYVIEW AVE
-----------------------------------------------------
City | NORTH KINGSTOWN
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02852-1207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-368-4263
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LYMPHEDEMA THERAPIST/OT
-----------------------------------------------------
Name | AMANDA SARAH BROWN
-----------------------------------------------------
Credential | OTR/L, CLT
-----------------------------------------------------
Telephone | 401-368-4263
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------