Basic Information
| Provider Information | |||||||||
| NPI: | 1710376827 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHANNON | ||||||||
| FirstName: | REGINA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 117 ELLENFIELD ST STE 101 | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029054513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017248400 | ||||||||
| FaxNumber: | 4017225280 | ||||||||
| Practice Location | |||||||||
| Address1: | 1011 VETERANS MEMORIAL PKWY | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 02915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014321000 | ||||||||
| FaxNumber: | 4014321500 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2015 | ||||||||
| LastUpdateDate: | 03/29/2019 | ||||||||
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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 | 1041C0700X | ISW02919 | RI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | CSW1778 | RI | N | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | GH57134 | 05 | RI | MEDICAID |