Provider Demographics
NPI:1154348803
Name:COLLABORATIVE FOR BEHAVIORAL HEALTH
Entity type:Organization
Organization Name:COLLABORATIVE FOR BEHAVIORAL HEALTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINCAL DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:FRAGOZA
Authorized Official - Suffix:
Authorized Official - Credentials:MSW,LICSW,LCDP
Authorized Official - Phone:401-245-5395
Mailing Address - Street 1:34 2ND ST
Mailing Address - Street 2:
Mailing Address - City:SWANSEA
Mailing Address - State:MA
Mailing Address - Zip Code:02777-3203
Mailing Address - Country:US
Mailing Address - Phone:508-324-5282
Mailing Address - Fax:401-245-5395
Practice Address - Street 1:654 METACOM AVE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:RI
Practice Address - Zip Code:02885-2300
Practice Address - Country:US
Practice Address - Phone:401-245-5395
Practice Address - Fax:401-245-5395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RICDP00146101YA0400X
RIISW007191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RICB30596Medicaid
RIDF04200Medicaid
RIDF04200Medicaid