Basic Information
| Provider Information | |||||||||
| NPI: | 1821022393 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAIN | ||||||||
| FirstName: | MARISSA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 FERA ST | ||||||||
| Address2: | #107 | ||||||||
| City: | NORTH PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029044100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4012357000 | ||||||||
| FaxNumber: | |||||||||
| 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: | 07/10/2006 | ||||||||
| 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 | 1041C0700X | ISW01731 | RI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | MB50349 | 05 | RI | MEDICAID | 0000031091 | 01 | RI | BLUE CROSS | OTHER | 0000041302 | 01 | RI | BLUE CHIP | OTHER |