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Individual provider Active NPI Psychiatric/Mental Health Nurse Practitioner · Ashaway, RI

NPI 1225978588 · NPPES record last updated Aug 19, 2026

Key facts

NPI
1225978588
Entity type
Individual (NPI type 1)
Primary specialty
Psychiatric/Mental Health Nurse Practitioner 363LP0808X
License
RN65323 (RI)
Practice address
361 Tomaquag Rd
Ashaway, RI 02804-2912
Phone
(401) 440-5528
NPI assigned
Mar 30, 2026
Sex
Male
Sole proprietor
Yes

Medicare participation

Medicare fee-for-service enrollment
Not listed in the public Medicare enrollment file
Eligible to order & refer
Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: No

National Provider Directory

Medicare enrollment (NPD)
No

State licenses

LicenseStateTypeSpecialty
RN65323RIMDMedical-Surgical Registered Nurse

Specialties & licenses

Specialty (taxonomy)CodeLicenseStatePrimary
Psychiatric/Mental Health Nurse Practitioner
Group: 193400000X SINGLE SPECIALTY GROUP
363LP0808X RN65323 RI Yes

Addresses

Primary practice location

361 Tomaquag Rd
Ashaway, RI 02804-2912

Mailing address

361 Tomaquag Rd
Ashaway, RI 02804-2912

Other practice location 1

17 Adelphi Ave
Providence, RI 02906-4119
Phone (718) 506-1115

Other practice location 2

398 Bellevue Ave
Newport, RI 02840-6955
Phone (718) 506-1115

Other providers in Ashaway, RI

All providers in Ashaway, RI · Psychiatric/Mental Health Nurse Practitioner in Rhode Island

Sources for this page

Verify at the official NPI Registry.