1811162316 NPI number — BROADWAY PSYCHOTHERAPY, INC.

Table of content: (NPI 1811162316)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811162316 NPI number — BROADWAY PSYCHOTHERAPY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BROADWAY PSYCHOTHERAPY, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
HEALTH BEHAVIOR CONSULTANTS, INC.
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1811162316
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/03/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
347 BROADWAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PROVIDENCE
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02909-1101
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-270-9808
Provider Business Mailing Address Fax Number:
401-354-7455

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
347 BROADWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PROVIDENCE
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02909-1101
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-270-9808
Provider Business Practice Location Address Fax Number:
401-354-7455
Provider Enumeration Date:
04/25/2008

Additional Information

Authorized Official

Authorized Official Last Name:
MIGNEAULT
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
P.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
401-270-9808

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  PS00585 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1041C0700X , with the licence number: ISW00174 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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