Basic Information
| Provider Information | |||||||||
| NPI: | 1104981448 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BORELLI-LOOMIS | ||||||||
| FirstName: | JANE | ||||||||
| MiddleName: | |||||||||
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| Credential: | LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 40 SAUNDERS BROOK RD | ||||||||
| Address2: | |||||||||
| City: | CHEPACHET | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028142003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4013311350 | ||||||||
| FaxNumber: | 4012773366 | ||||||||
| Practice Location | |||||||||
| Address1: | 134 THURBERS AVE | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029054754 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4013311350 | ||||||||
| FaxNumber: | 4012773366 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 1041C0700X | ISW00285 | RI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | JB41884 | 05 | RI | MEDICAID |