1154348803 NPI number — COLLABORATIVE FOR BEHAVIORAL HEALTH

Table of content: (NPI 1154348803)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154348803 NPI number — COLLABORATIVE FOR BEHAVIORAL HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COLLABORATIVE FOR BEHAVIORAL HEALTH
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154348803
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/09/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
34 2ND ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SWANSEA
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02777-3203
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-324-5282
Provider Business Mailing Address Fax Number:
401-245-5395

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
654 METACOM AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WARREN
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02885-2300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-245-5395
Provider Business Practice Location Address Fax Number:
401-245-5395
Provider Enumeration Date:
07/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FRAGOZA
Authorized Official First Name:
DENISE
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
CLINCAL DIRECTOR
Authorized Official Telephone Number:
401-245-5395

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  CDP00146 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: ISW00719 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: CB30596 , issued by the state of ( RI ) . This identifiers is of the category "MEDICAID".
  • Identifier: DF04200 , issued by the state of ( RI ) . This identifiers is of the category "MEDICAID".




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