Provider Demographics
NPI:1952622953
Name:PSYCHOLOGISTS AT JEFFERSON GATEWAY, LLC
Entity Type:Organization
Organization Name:PSYCHOLOGISTS AT JEFFERSON GATEWAY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:CECILIA
Authorized Official - Middle Name:MARIA
Authorized Official - Last Name:DUARTE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:401-921-5400
Mailing Address - Street 1:931 JEFFERSON BLVD
Mailing Address - Street 2:SUITE 2009
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-2234
Mailing Address - Country:US
Mailing Address - Phone:401-921-5400
Mailing Address - Fax:401-921-5402
Practice Address - Street 1:931 JEFFERSON BLVD
Practice Address - Street 2:SUITE 2009
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886-2234
Practice Address - Country:US
Practice Address - Phone:401-921-5400
Practice Address - Fax:401-921-5402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-14
Last Update Date:2010-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPS01162103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty