Provider Demographics
NPI:1841209210
Name:HETHERINGTON, NANCY CAROL (LICSW)
Entity Type:Individual
Prefix:MS
First Name:NANCY
Middle Name:CAROL
Last Name:HETHERINGTON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 WAYLAND AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-4318
Mailing Address - Country:US
Mailing Address - Phone:401-709-9497
Mailing Address - Fax:401-709-3776
Practice Address - Street 1:120 WAYLAND AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-4318
Practice Address - Country:US
Practice Address - Phone:401-709-9497
Practice Address - Fax:401-709-3776
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2013-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW011511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI410721OtherPSYCHOTHERAPIST
RI8090041211OtherMEDICARE PTAN
RI9004121Medicaid
RI26586-3OtherPSYCHOTHERAPIST
RI62-83298OtherPSYCHOTHERAPIST