=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770849010
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHRISTOPHER M DORVAL LICSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/11/2012
-----------------------------------------------------
Last Update Date | 12/17/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1524 ATWOOD AVE STE 244
-----------------------------------------------------
City | JOHNSTON
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02919-3228
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-626-0169
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 64 EMERALD WAY
-----------------------------------------------------
City | NORTH SCITUATE
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02857-2860
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-626-0169
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 17440
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 200020
-----------------------------------------------------
License Number State | RI
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 224236
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | ISW02895
-----------------------------------------------------
License Number State | RI
-----------------------------------------------------