Basic Information
| Provider Information | |||||||||
| NPI: | 1750482584 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DWYER | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | F. | ||||||||
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| Credential: | PCNS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 83 ROSEGARDEN ST | ||||||||
| Address2: | |||||||||
| City: | WARWICK | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028882812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014675020 | ||||||||
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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: | 09/26/2006 | ||||||||
| 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 | 163WP0808X | PPNS00004 | RI | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 621655 | 01 | RI | UNITED HEALTH | OTHER | MD03432 | 05 | RI | MEDICAID | 407879 | 01 | RI | BLUE CHIP | OTHER | BLUE CROSS | 01 | RI | 0000022382 | OTHER |