| Broadway Psychotherapy, Inc. | |
|
347 Broadway Providence RI 02909-1101 | |
| (401) 270-9808 | |
| (401) 354-7455 |
| Full Name | Broadway Psychotherapy, Inc. |
|---|---|
| Speciality | Psychologist |
| Location | 347 Broadway, Providence, Rhode Island |
| Authorized Official Name and Position | Jeffrey P. Migneault (PRESIDENT) |
| Authorized Official Contact | 4012709808 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Broadway Psychotherapy, Inc. 347 Broadway Providence RI 02909-1101 Ph: (401) 270-9808 | Broadway Psychotherapy, Inc. 347 Broadway Providence RI 02909-1101 Ph: (401) 270-9808 |
| NPI Number | 1811162316 |
|---|---|
| Provider Enumeration Date | 04/25/2008 |
| Last Update Date | 05/03/2017 |
| Medicare PECOS PAC ID | 5597941286 |
|---|---|
| Medicare Enrollment ID | O20110513000299 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1811162316 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 103TC0700X | Psychologist - Clinical | PS00585 (Rhode Island) | Primary |
| 1041C0700X | Social Worker - Clinical | ISW00174 (Rhode Island) | Secondary |
| Provider Name | Jeffrey P Migneault |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1295883965 PECOS PAC ID: 3173525979 Enrollment ID: I20070207000541 |
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