Provider Demographics
NPI:1508028234
Name:BRATHWAITE-GARDNER, ALLYSON (PHD)
Entity Type:Individual
Prefix:
First Name:ALLYSON
Middle Name:
Last Name:BRATHWAITE-GARDNER
Suffix:
Gender:F
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:PO BOX 23013
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-0394
Mailing Address - Country:US
Mailing Address - Phone:401-261-2062
Mailing Address - Fax:
Practice Address - Street 1:ONE RICHMOND SQUARE
Practice Address - Street 2:SUITE 154E
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:20904
Practice Address - Country:US
Practice Address - Phone:401-261-2062
Practice Address - Fax:401-432-6533
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-25
Last Update Date:2015-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPS01053103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling