Provider Demographics
NPI:1861944969
Name:INNOVATIVE THERAPEUTICS OF RHODE ISLAND LLC
Entity type:Organization
Organization Name:INNOVATIVE THERAPEUTICS OF RHODE ISLAND LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC
Authorized Official - Phone:781-964-9446
Mailing Address - Street 1:316 WILLETT AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:RI
Mailing Address - Zip Code:02915-2511
Mailing Address - Country:US
Mailing Address - Phone:401-270-2468
Mailing Address - Fax:781-964-9446
Practice Address - Street 1:316 WILLETT AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:RI
Practice Address - Zip Code:02915-2511
Practice Address - Country:US
Practice Address - Phone:401-270-2468
Practice Address - Fax:781-964-9446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-25
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIAPRN01440363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty