Basic Information
| Provider Information | |||||||||
| NPI: | 1437175718 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CRISTO | ||||||||
| FirstName: | STACY | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | LMHC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 139 PAYTON ST | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029051300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4012357000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 55 JOHN A CUMMINGS WAY | ||||||||
| Address2: | |||||||||
| City: | WOONSOCKET | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028953247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4012357000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 106H00000X | MHC00247 | RI | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | SC58301 | 05 | RI | MEDICAID |