Basic Information
| Provider Information | |||||||||
| NPI: | 1528010584 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THURBER | ||||||||
| FirstName: | EARLE | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 249 ROOSEVELT AVE | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | PAWTUCKET | ||||||||
| State: | WI | ||||||||
| PostalCode: | 02867 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017248400 | ||||||||
| FaxNumber: | 4013651100 | ||||||||
| Practice Location | |||||||||
| Address1: | 351 EAST AVE | ||||||||
| Address2: | |||||||||
| City: | PAWTUCKET | ||||||||
| State: | RI | ||||||||
| PostalCode: | 02860 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017254412 | ||||||||
| FaxNumber: | 4017285310 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | ISW01262 | RI | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | ET23917 | 05 | RI | MEDICAID |