Basic Information
| Provider Information | |||||||||
| NPI: | 1356437396 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROBERTS | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | IV | ||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 637 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WOONSOCKET | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028955758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017693186 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 55 JOHN A CUMMINGS WAY | ||||||||
| Address2: | |||||||||
| City: | WOONSOCKET | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028953247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4012357000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 10/30/2012 | ||||||||
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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 | 101Y00000X | PC396 | RI | N | Behavioral Health & Social Service Providers | Counselor | 101YA0400X | CDP00537 | RI | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | LR56123 | 05 | RI | MEDICAID |