Basic Information
| Provider Information | |||||||||
| NPI: | 1689735078 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARL | ||||||||
| FirstName: | LAUREN | ||||||||
| MiddleName: | PATRICIA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RI | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GRANDINETTI | ||||||||
| OtherFirstName: | LAUREN | ||||||||
| OtherMiddleName: | PATRICIA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 24 RIVERVIEW DR | ||||||||
| Address2: | |||||||||
| City: | CUMBERLAND | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028645427 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5169913005 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 400 RESERVOIR AVE STE 2F | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029073565 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004558726 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2006 | ||||||||
| LastUpdateDate: | 07/06/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.