Basic Information
| Provider Information | |||||||||
| NPI: | 1053536748 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MENIHAN | ||||||||
| FirstName: | KAITLIN | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 EDDY STREET | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 02905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4015339100 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1000 EDDY STREET | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 02905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4015339100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 292177 | 01 | RI | EI BCROSS | OTHER | ES01788 | 05 | RI | MEDICAID | 412296 | 01 | RI | EI BCHIP | OTHER | 6400144 | 01 | RI | EI UNITED | OTHER | 2092 | 01 | RI | EI NHPRC | OTHER |