Basic Information
| Provider Information | |||||||||
| NPI: | 1356406672 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FLYNN | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | |||||||||
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| Credential: | LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 286 PARK PL | ||||||||
| Address2: | |||||||||
| City: | WOONSOCKET | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028954426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4013311350 | ||||||||
| FaxNumber: | 4012773366 | ||||||||
| Practice Location | |||||||||
| Address1: | 55 HOPE ST | ||||||||
| Address2: | FAMILY SERVICE OF RHODE ISLAND | ||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029062001 | ||||||||
| 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 | ISW01467 | RI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1021740 | 01 | GROUP NHP NUMBER | OTHER | 410063 | 01 | BLUE CHIP | OTHER | 9638-4 | 01 | BLUE CROSS BLUE SHIELD | OTHER | KF29870 | 05 | RI | MEDICAID |