Provider Demographics
NPI:1124060439
Name:DIMINO, KENDRA (LICSW)
Entity type:Individual
Prefix:
First Name:KENDRA
Middle Name:
Last Name:DIMINO
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:KENDRA
Other - Middle Name:
Other - Last Name:CORRIVEAU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICSW
Mailing Address - Street 1:10 ORMS ST
Mailing Address - Street 2:SUITE 110
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02904-2228
Mailing Address - Country:US
Mailing Address - Phone:401-453-0666
Mailing Address - Fax:401-453-9619
Practice Address - Street 1:1524 ATWOOD AVE
Practice Address - Street 2:SUITE 213
Practice Address - City:JOHNSTON
Practice Address - State:RI
Practice Address - Zip Code:02919-3228
Practice Address - Country:US
Practice Address - Phone:401-351-0400
Practice Address - Fax:401-351-0410
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW014301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI29289-6OtherBLUE SHIELD PROVIDER #
RI412739OtherBLUE CHIP PROVIDER #