Basic Information
| Provider Information | |||||||||
| NPI: | 1619989829 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FITZELLE-JONES | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | |||||||||
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| Credential: | LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 357 PEQUOT AVE | ||||||||
| Address2: | |||||||||
| City: | WARWICK | ||||||||
| State: | RI | ||||||||
| PostalCode: | 02889 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017329310 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2756 POST RD | ||||||||
| Address2: | |||||||||
| City: | WARWICK | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028863003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4016916000 | ||||||||
| FaxNumber: | 4017387718 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2006 | ||||||||
| LastUpdateDate: | 09/20/2011 | ||||||||
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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 | 104100000X | 1SW00687 | RI | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | MF03352 | 05 | RI | MEDICAID | 301088 | 01 | RI | BLUE CROSS | OTHER | 6215751 | 01 | RI | VBH | OTHER | 406398 | 01 | RI | BLUE CHIP | OTHER |