Provider Demographics
NPI:1740460872
Name:HOME PORT THERAPY
Entity type:Organization
Organization Name:HOME PORT THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:REYNARD
Authorized Official - Middle Name:
Authorized Official - Last Name:BULLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:MS LMFT
Authorized Official - Phone:401-932-1181
Mailing Address - Street 1:23 NORTH RD STE A25
Mailing Address - Street 2:
Mailing Address - City:PEACE DALE
Mailing Address - State:RI
Mailing Address - Zip Code:02879-2176
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:23 NORTH RD STE A25
Practice Address - Street 2:
Practice Address - City:PEACE DALE
Practice Address - State:RI
Practice Address - Zip Code:02879-2176
Practice Address - Country:US
Practice Address - Phone:401-932-1181
Practice Address - Fax:401-783-1154
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-06
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMFT00100261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health