| Name: | Braver Medical, PLLC |
| Jurisdiction: | Rhode Island |
| Entity type: | Foreign Limited Liability Company |
| Status: | Activ |
| Date of Organization in Rhode Island: | 18 Aug 2021 (3 years ago) |
| Branch of: | Braver Medical, PLLC, CONNECTICUT (Company Number 2327260) |
| Identification Number: | 001728300 |
| ZIP code: | 02806 |
| County: | Bristol County |
| Place of Formation: | CONNECTICUT |
| Principal Address: | 67 BAY ROAD, BARRINGTON, RI, 02806, USA |
| Mailing Address: | 51 STANDISH RD, WELLESLEY, MA, 02481, USA |
| Purpose: | BEHAVIORAL HEALTH THERAPY FOR CHILDREN WITH ANXIETY. |
| NAICS: | 621112 - Offices of Physicians, Mental Health Specialists |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1972265536 | 2021-10-12 | 2022-11-20 | 67 BAY RD, BARRINGTON, RI, 028064751, US | 1275 WAMPANOAG TRL STE 3C, RIVERSIDE, RI, 029151217, US | |||||||||||||||||||||||||||||||||||||||||||||
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| Phone | +1 917-697-2890 |
| Fax | 4019032192 |
| Phone | +1 401-206-0304 |
| Fax | 4013436466 |
Authorized person
| Name | BRADY CASE |
| Role | MEMBER |
| Phone | 9176972890 |
Taxonomy
| Taxonomy Code | 103TC0700X - Clinical Psychologist |
| Is Primary | No |
| Taxonomy Code | 103TC2200X - Clinical Child & Adolescent Psychologist |
| Is Primary | No |
| Taxonomy Code | 2084P0804X - Child & Adolescent Psychiatry Physician |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | PSYCHOLOGIST LICENSE |
| Number | PS01333 |
| State | RI |
| Issuer | PSYCHOLOGIST LICENSE |
| Number | PS00846 |
| State | RI |
| Issuer | MEDICAL LICENSE |
| Number | MD12323 |
| State | RI |
| Name | Role | Address |
|---|---|---|
| NATIONAL REGISTERED AGENTS, INC. | Agent | 450 VETERANS MEMORIAL PARKWAY SUITE 7A, EAST PROVIDENCE, RI, 02914, USA |
| Number | Name | File Date |
|---|---|---|
| 202450533660 | Annual Report | 2024-04-09 |
| 202332142560 | Annual Report | 2023-03-31 |
| 202222917360 | Annual Report | 2022-09-20 |
| 202219243500 | Revocation Notice For Failure to File An Annual Report | 2022-06-22 |
| 202100228140 | Application for Registration | 2021-08-18 |
Date of last update: 28 Oct 2024
Sources: Rhode Island Department of State
