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1 Richmond Sq Ste 321w Providence RI 02906-5156 | |
| (508) 812-0613 | |
| Not Available |
| Full Name | |
|---|---|
| Speciality | Community/Behavioral Health |
| Location | 1 Richmond Sq Ste 321w, Providence, Rhode Island |
| Authorized Official Name and Position | Krystal Vasconcelos (DIRECTOR OF CLINICAL OPERATIONS) |
| Authorized Official Contact | 5088120613 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
1 Richmond Sq Ste 321w Providence RI 02906-5156 Ph: (508) 812-0613 | 1 Richmond Sq Ste 321w Providence RI 02906-5156 Ph: (508) 812-0613 |
| NPI Number | 1124585427 |
|---|---|
| Provider Enumeration Date | 02/23/2019 |
| Last Update Date | 04/19/2022 |
| Certification Date | 04/19/2022 |
| Medicare PECOS PAC ID | 9931513280 |
|---|---|
| Medicare Enrollment ID | O20210127001498 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1124585427 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 251S00000X | Community/behavioral Health | (* (Not Available)) | Primary |
| Provider Name | Krystal Vasconcelos |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1720414337 PECOS PAC ID: 5294961298 Enrollment ID: I20210127001791 |
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