Basic Information
Provider Information | |||||||||
NPI: | 1093713174 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NEWPORT COUNTY COMMUNITY MENTAL HEALTH CENTER, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 127 JOHNNY CAKE HILL RD | ||||||||
Address2: |   | ||||||||
City: | MIDDLETOWN | ||||||||
State: | RI | ||||||||
PostalCode: | 028425674 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4018461213 | ||||||||
FaxNumber: | 4018489151 | ||||||||
Practice Location | |||||||||
Address1: | 127 JOHNNY CAKE HILL RD | ||||||||
Address2: |   | ||||||||
City: | MIDDLETOWN | ||||||||
State: | RI | ||||||||
PostalCode: | 028425674 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4018461213 | ||||||||
FaxNumber: | 4018489151 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/12/2005 | ||||||||
LastUpdateDate: | 11/15/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | COSTA | ||||||||
AuthorizedOfficialFirstName: | STEPHANIE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VP OF ADMINISTRATION | ||||||||
AuthorizedOfficialTelephone: | 4018461213 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X |   |   | N |   | Agencies | Case Management |   | 251S00000X |   |   | N |   | Agencies | Community/Behavioral Health |   | 261QM0801X | 626 | RI | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
ID | Type | State | Issuer | Description | 9001892 | 05 | RI |   | MEDICAID | 1892 | 01 | RI | BLUE CROSS BLUE SHIELD | OTHER | NC02211 | 05 | RI |   | MEDICAID |