Provider Demographics
NPI:1982784674
Name:REITER, IRA H (PHD)
Entity type:Individual
Prefix:DR
First Name:IRA
Middle Name:H
Last Name:REITER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:347 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02909-1101
Mailing Address - Country:US
Mailing Address - Phone:401-782-8440
Mailing Address - Fax:
Practice Address - Street 1:347 BROADWAY
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02909-1101
Practice Address - Country:US
Practice Address - Phone:401-782-8440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI407103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI3593-6OtherRI BC/BS PRIVDER NUMBER
RIIR00380Medicaid