Provider Demographics
NPI:1043296916
Name:BREEN, ROBERT B (PHD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:B
Last Name:BREEN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:593 EDDY ST
Mailing Address - Street 2:APC 978
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-4923
Mailing Address - Country:US
Mailing Address - Phone:401-444-4318
Mailing Address - Fax:401-444-7865
Practice Address - Street 1:235 PLAIN ST
Practice Address - Street 2:SUITE 501
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02905-3240
Practice Address - Country:US
Practice Address - Phone:401-444-7442
Practice Address - Fax:401-444-7109
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPS00753103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
007009162Medicare ID - Type Unspecified
P37611Medicare UPIN