Organization
HOME PORT THERAPY
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. REYNARD BULLOCK MS LMFT (OWNER)
(401) 932-1181
Entity
Organization
Contact information
Practice address
23 NORTH RD STE A25, PEACE DALE, RI 02879-2176
(401) 932-1181
(401) 783-1154
Mailing address
23 NORTH RD STE A25, PEACE DALE, RI 02879-2176
Taxonomy
Speciality
Code
Description
License number
State
261QM0850X
Adult Mental Health Clinic/Center
Primary
MFT00100
RI
Other
Enumeration date
11/06/2007
Last updated
11/06/2007
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