Basic Information
| Provider Information | |||||||||
| NPI: | 1528347895 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BEAN | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | MCKENZIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MA,LMHC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1443 HARTFORD AVE | ||||||||
| Address2: | |||||||||
| City: | JOHNSTON | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029193224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017248400 | ||||||||
| FaxNumber: | 4017225280 | ||||||||
| Practice Location | |||||||||
| Address1: | 1443 HARTFORD AVE | ||||||||
| Address2: | |||||||||
| City: | JOHNSTON | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029193224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017248400 | ||||||||
| FaxNumber: | 4017225280 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2011 | ||||||||
| LastUpdateDate: | 10/08/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | MHC00605 | RI | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | GH57134 | 05 | RI | MEDICAID |