Basic Information
| Provider Information | |||||||||
| NPI: | 1528347093 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DISCOVERY HOUSE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 48 DARTMOUTH RD | ||||||||
| Address2: | |||||||||
| City: | CRANSTON | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029206135 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 48 DARTMOUTH RD | ||||||||
| Address2: | |||||||||
| City: | CRANSTON | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029206135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017621511 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2011 | ||||||||
| LastUpdateDate: | 08/15/2011 | ||||||||
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| AuthorizedOfficialLastName: | LILLI | ||||||||
| AuthorizedOfficialFirstName: | LOUIS | ||||||||
| AuthorizedOfficialMiddleName: | NICHOLAS | ||||||||
| AuthorizedOfficialTitleorPosition: | SUBSTANCE ABUSE COUNSELOR | ||||||||
| AuthorizedOfficialTelephone: | 4017621511 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | M.A. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 05044312 | 05 | RI | MEDICAID |