Basic Information
| Provider Information | |||||||||
| NPI: | 1053467936 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REINERT | ||||||||
| FirstName: | CAROL | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | LCDP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1274 MIDDLEBRIDGE RD | ||||||||
| Address2: | |||||||||
| City: | WAKEFIELD | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028797149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4013311350 | ||||||||
| FaxNumber: | 4012773366 | ||||||||
| Practice Location | |||||||||
| Address1: | 650 TEN ROD RD | ||||||||
| Address2: | UNIT 13 | ||||||||
| City: | NORTH KINGSTOWN | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028524238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4013311350 | ||||||||
| FaxNumber: | 4012773366 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2007 | ||||||||
| LastUpdateDate: | 10/24/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | LCDP00064 | RI | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | MHC00381 | RI | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | CR48918 | 05 | RI | MEDICAID |