Basic Information
| Provider Information | |||||||||
| NPI: | 1497273718 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TIMMINS | ||||||||
| FirstName: | MARISA | ||||||||
| MiddleName: | COURTNEY | ||||||||
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| Credential: | SPEECH THERAPIST | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 EDDY ST | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029054739 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4015339100 | ||||||||
| FaxNumber: | 4015339105 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 EDDY ST | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029054739 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4015339100 | ||||||||
| FaxNumber: | 4015339105 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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 | 235Z00000X | SP00375-P | RI | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | ES01788 | 05 | RI | MEDICAID | 0614 | 01 | RI | NEIGHBORHOOD HEALTH OF RI | OTHER | SB870 | 01 | RI | BLUE CROSS | OTHER |