Provider Demographics
NPI:1194377374
Name:TEAM ROCKSTAR SPORTS
Entity type:Organization
Organization Name:TEAM ROCKSTAR SPORTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LEAD CLINICIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:A
Authorized Official - Last Name:MOLINA
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:401-255-6906
Mailing Address - Street 1:219 DUNEDIN ST
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02920-7034
Mailing Address - Country:US
Mailing Address - Phone:401-569-2535
Mailing Address - Fax:
Practice Address - Street 1:1314 FALL RIVER AVE
Practice Address - Street 2:
Practice Address - City:SEEKONK
Practice Address - State:MA
Practice Address - Zip Code:02771-5927
Practice Address - Country:US
Practice Address - Phone:401-255-6906
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-09
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty