=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952651895
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHILDREN IN BALANCE PSYCHOLOGICAL ASSOCIATES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/19/2012
-----------------------------------------------------
Last Update Date | 04/26/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 575 E MAIN RD 4
-----------------------------------------------------
City | MIDDLETOWN
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02842-5528
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-962-7364
-----------------------------------------------------
Fax | 401-619-7766
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | P.O. BOX 577
-----------------------------------------------------
City | SOMERSET
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02726
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-962-7364
-----------------------------------------------------
Fax | 401-619-7766
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MISS TIFFANY BOURQUIN
-----------------------------------------------------
Credential | LMHC
-----------------------------------------------------
Telephone | 508-962-7364
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | MHC00502
-----------------------------------------------------
License Number State | RI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 7566
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | CSW01724
-----------------------------------------------------
License Number State | RI
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 02472
-----------------------------------------------------
License Number State | RI
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 6722
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 7566
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 7566
-----------------------------------------------------
License Number State | RI
-----------------------------------------------------
Taxonomy #8
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 00547
-----------------------------------------------------
License Number State | RI
-----------------------------------------------------