Provider Demographics
NPI:1942605522
Name:ELINE, BRENDA DIANE
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:DIANE
Last Name:ELINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 KING CHARLES DR STE A2
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:RI
Mailing Address - Zip Code:02871-1364
Mailing Address - Country:US
Mailing Address - Phone:401-683-0857
Mailing Address - Fax:401-293-0142
Practice Address - Street 1:11 KING CHARLES DR STE A2
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:RI
Practice Address - Zip Code:02871-1364
Practice Address - Country:US
Practice Address - Phone:401-683-0857
Practice Address - Fax:401-293-0142
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-25
Last Update Date:2014-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RICDP595101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)