Provider Demographics
NPI:1447302450
Name:THEODORE, GERALDINE (SLP)
Entity type:Individual
Prefix:
First Name:GERALDINE
Middle Name:
Last Name:THEODORE
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 W INDEPENDENCE WAY
Mailing Address - Street 2:SUITE I
Mailing Address - City:KINGSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02881-1124
Mailing Address - Country:US
Mailing Address - Phone:401-874-2577
Mailing Address - Fax:401-874-4404
Practice Address - Street 1:25 W INDEPENDENCE WAY
Practice Address - Street 2:SUITE I
Practice Address - City:KINGSTON
Practice Address - State:RI
Practice Address - Zip Code:02881-1124
Practice Address - Country:US
Practice Address - Phone:401-874-2577
Practice Address - Fax:401-874-4404
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RISP00272235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI2626-0Medicare UPIN
RI4600118Medicare UPIN
RI410093Medicare UPIN