Basic Information
Provider Information | |||||||||
NPI: | 1598833535 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FAMILY SERVICE OF RHODE ISLAND, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 9 PLEASANT ST | ||||||||
Address2: |   | ||||||||
City: | PROVIDENCE | ||||||||
State: | RI | ||||||||
PostalCode: | 029061715 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4013311350 | ||||||||
FaxNumber: | 4012773366 | ||||||||
Practice Location | |||||||||
Address1: | 55 HOPE ST | ||||||||
Address2: |   | ||||||||
City: | PROVIDENCE | ||||||||
State: | RI | ||||||||
PostalCode: | 02903 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4013311350 | ||||||||
FaxNumber: | 4012773366 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/30/2006 | ||||||||
LastUpdateDate: | 05/13/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PELLETIER | ||||||||
AuthorizedOfficialFirstName: | PHYLLIS | ||||||||
AuthorizedOfficialMiddleName: | R | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
AuthorizedOfficialTelephone: | 4013311350 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/13/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X |   |   | N |   | Agencies | Case Management |   | 261QM0855X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 261QR0405X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 261QM0850X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health |
ID Information
ID | Type | State | Issuer | Description | 050258558 | 01 |   | MHN | OTHER | 1021740 | 01 |   | NEIGHBORHOOD HEALTH | OTHER | 9638 | 01 |   | BLUE CROSS BLUE SHIELD | OTHER | 050285585 | 01 |   | VALUE OPTIONS | OTHER | 410842 | 01 |   | BLUE CHIP | OTHER | 9009638 | 05 | RI |   | MEDICAID |