Basic Information
| Provider Information | |||||||||
| NPI: | 1184851065 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AUDETTE | ||||||||
| FirstName: | GRACIOUS | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSW, LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7 RHODE ISLAND AVE | ||||||||
| Address2: | |||||||||
| City: | NEWPORT | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028402606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4018461213 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7 RHODE ISLAND AVE | ||||||||
| Address2: | |||||||||
| City: | NEWPORT | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028402606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4018461213 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2009 | ||||||||
| LastUpdateDate: | 04/04/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | CSW01202 | RI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.