Basic Information
| Provider Information | |||||||||
| NPI: | 1013928696 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHILIBERT | ||||||||
| FirstName: | SUSANNA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | LICSW, LCDP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 OLD COUNTY RD | ||||||||
| Address2: | |||||||||
| City: | BARRINGTON | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028061602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4012461195 | ||||||||
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| Practice Location | |||||||||
| Address1: | EAST BAY MENTAL HEALTH CENTER | ||||||||
| Address2: | 2 OLD COUNTY ROAD | ||||||||
| City: | BARRINGTON | ||||||||
| State: | RI | ||||||||
| PostalCode: | 02806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4012461195 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2006 | ||||||||
| LastUpdateDate: | 04/28/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | LCDP00050 | RI | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 104100000X | 1SW01479 | RI | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | ISW01479 | RI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 41006 | 01 | BLUE CHIP | OTHER | 264772 | 01 | BLUE CROSS | OTHER | 62-47775 | 01 | UBH | OTHER |