Basic Information
| Provider Information | |||||||||
| NPI: | 1144234246 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROMAN | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | J. | ||||||||
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| Credential: | LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 223 PROSSER TRL | ||||||||
| Address2: | |||||||||
| City: | CHARLESTOWN | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028132840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4013311350 | ||||||||
| FaxNumber: | 4012773366 | ||||||||
| Practice Location | |||||||||
| Address1: | 55 HOPE ST | ||||||||
| Address2: | C/O FAMILY SERVICE OF RHODE ISLAND | ||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029062001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4013311350 | ||||||||
| FaxNumber: | 4012773366 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | ISW01349 | RI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 30315-8 | 01 | RI | BLUE CROSS/SHIELD | OTHER | 478002 | 01 | VALUE OPTIONS | OTHER | 408143 | 01 | RI | BLUE CHIP | OTHER | UBH | 01 | 6232362 | OTHER | NHP | 01 | 1021740 GROUP | OTHER | MR33981 | 05 | RI | MEDICAID |