Provider Demographics
NPI:1790207876
Name:CENTER FOR DYNAMIC AND BEHAVIORAL THERAPY LLC
Entity Type:Organization
Organization Name:CENTER FOR DYNAMIC AND BEHAVIORAL THERAPY LLC
Other - Org Name:PVD PSYCHOLOGICAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:ISSA
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:401-330-5882
Mailing Address - Street 1:11 S ANGELL ST # 405
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-5206
Mailing Address - Country:US
Mailing Address - Phone:401-330-5882
Mailing Address - Fax:401-226-0137
Practice Address - Street 1:382 THAYER ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-1558
Practice Address - Country:US
Practice Address - Phone:401-330-5882
Practice Address - Fax:401-226-0137
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-11
Last Update Date:2021-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPS01616103TC0700X
RIPS01615103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty