Basic Information
| Provider Information | |||||||||
| NPI: | 1508094590 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUTTARO | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | ANNE | ||||||||
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| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 593 EDDY ST | ||||||||
| Address2: | APC 978 | ||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029034923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014444318 | ||||||||
| FaxNumber: | 4014447865 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 HOPPIN ST | ||||||||
| Address2: | SUITE 317 | ||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029034141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017938740 | ||||||||
| FaxNumber: | 4014447865 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2009 | ||||||||
| LastUpdateDate: | 06/18/2014 | ||||||||
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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 | 103T00000X | PS01131 | RI | Y | Behavioral Health & Social Service Providers | Psychologist | 103TC2200X | PS01131 | RI | N | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | 103G00000X | PS01131 | RI | N | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |
ID Information
| ID | Type | State | Issuer | Description | PS01131 | 01 | RI | RI PROFESSIONAL LICENSE | OTHER |