Provider Demographics
NPI:1720142409
Name:MUSHOLT, DANIEL MARTIN (MSW)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:MARTIN
Last Name:MUSHOLT
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 ANSON DR
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:RI
Mailing Address - Zip Code:02915-2763
Mailing Address - Country:US
Mailing Address - Phone:401-454-4540
Mailing Address - Fax:
Practice Address - Street 1:501 ANGELL ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-4467
Practice Address - Country:US
Practice Address - Phone:401-454-4540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW 0004191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI7450 6OtherBC BS ID