Basic Information
| Provider Information | |||||||||
| NPI: | 1518919166 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MORELLO | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MSPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MENCARINI | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | MSPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 721 RESERVOIR AVE | ||||||||
| Address2: | |||||||||
| City: | CRANSTON | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029104430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4019464250 | ||||||||
| FaxNumber: | 4012755645 | ||||||||
| Practice Location | |||||||||
| Address1: | 721 RESERVOIR AVE | ||||||||
| Address2: | |||||||||
| City: | CRANSTON | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029104430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4019464250 | ||||||||
| FaxNumber: | 4012755645 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 06/07/2013 | ||||||||
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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 | 225100000X | PT01482 | RI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 406540 | 01 | RI | BLUECHIP RI IND. ID # | OTHER | 007057123 | 01 | RI | MEDICARE PTAN | OTHER |