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General NPI Number Information
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NPI Number | 1811162316
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Entity Type | Organization
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Legal Business Name | BROADWAY PSYCHOTHERAPY, INC.
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Dates
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Enumeration Date | 04/25/2008
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Last Update Date | 05/03/2017
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Provider Practice Location Address
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Address Line | 347 BROADWAY
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City | PROVIDENCE
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State | RI
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Zip | 02909-1101
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Country | US
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Telephone | 401-270-9808
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Fax | 401-354-7455
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Provider Business Mailing Address
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Address Line | 347 BROADWAY
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City | PROVIDENCE
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State | RI
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Zip | 02909-1101
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Country | US
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Telephone | 401-270-9808
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Fax | 401-354-7455
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JEFFREY P. MIGNEAULT
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Credential | PH.D.
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Telephone | 401-270-9808
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | ISW00174
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License Number State | RI
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PS00585
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License Number State | RI
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