Basic Information
| Provider Information | |||||||||
| NPI: | 1912092040 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MESSORE | ||||||||
| FirstName: | PAMELA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2420 PLAINFIELD PIKE | ||||||||
| Address2: | |||||||||
| City: | JOHNSTON | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029195608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4019432159 | ||||||||
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| Practice Location | |||||||||
| Address1: | 181 CUMBERLAND ST | ||||||||
| Address2: | |||||||||
| City: | WOONSOCKET | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028953301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4012357000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| 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 | 101YA0400X | LCDP00245 | RI | X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | ISW01266 | RI | X | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 0000413043 | 01 | RI | BLUE CROSS | OTHER | 6248195 | 01 | RI | UNITED HEALTH | OTHER | 0000029999 | 01 | RI | BLUE CHIP | OTHER | PM57195 | 05 | RI | MEDICAID |