=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427392075
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OCEAN STATE BEHAVIORAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/20/2012
-----------------------------------------------------
Last Update Date | 07/14/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2733 POST RD
-----------------------------------------------------
City | WARWICK
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02886-3041
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-291-4825
-----------------------------------------------------
Fax | 401-291-4918
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2733 POST RD
-----------------------------------------------------
City | WARWICK
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02886-3041
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-291-4825
-----------------------------------------------------
Fax | 401-291-4918
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. STEPHEN WILLIAM PATCH
-----------------------------------------------------
Credential | MPA
-----------------------------------------------------
Telephone | 912-223-9758
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------