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General NPI Number Information
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NPI Number | 1952622953
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Entity Type | Organization
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Legal Business Name | PSYCHOLOGISTS AT JEFFERSON GATEWAY, LLC
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Dates
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Enumeration Date | 06/14/2010
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Last Update Date | 07/22/2010
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Provider Practice Location Address
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Address Line | 931 JEFFERSON BLVD SUITE 2009
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City | WARWICK
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State | RI
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Zip | 02886-2234
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Country | US
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Telephone | 401-921-5400
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Fax | 401-921-5402
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Provider Business Mailing Address
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Address Line | 931 JEFFERSON BLVD SUITE 2009
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City | WARWICK
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State | RI
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Zip | 02886-2234
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Country | US
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Telephone | 401-921-5400
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Fax | 401-921-5402
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Authorized Official
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Title or Position | PSYCHOLOGIST
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Name | CECILIA MARIA DUARTE
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Credential | PHD
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Telephone | 401-921-5400
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PS01162
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License Number State | RI
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