1104919117 NPI number — MISS KELLI RIVELLI LICSW

Table of content: MISS KELLI RIVELLI LICSW (NPI 1104919117)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104919117 NPI number — MISS KELLI RIVELLI LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RIVELLI
Provider First Name:
KELLI
Provider Middle Name:
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
LICSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1104919117
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/05/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1126 HARTFORD AVE
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
JOHNSTON
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02919-7130
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-351-2750
Provider Business Mailing Address Fax Number:
401-351-7002

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1126 HARTFORD AVE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
JOHNSTON
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02919-7130
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-351-2750
Provider Business Practice Location Address Fax Number:
401-351-7002
Provider Enumeration Date:
10/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X , with the licence number:  L.C.D.P. # NOT RCVD , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: ISW04259 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: TT24187 , issued by the state of ( RI ) . This identifiers is of the category "MEDICAID".




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