Provider Demographics
NPI:1962697961
Name:PREVOST-RICARDO, ALFRIDE (PMHNP-BC)
Entity type:Individual
Prefix:MR
First Name:ALFRIDE
Middle Name:
Last Name:PREVOST-RICARDO
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 JAQUES AVE
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01610-2476
Mailing Address - Country:US
Mailing Address - Phone:508-860-1000
Mailing Address - Fax:508-752-0577
Practice Address - Street 1:40 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:LEOMINSTER
Practice Address - State:MA
Practice Address - Zip Code:01453-3233
Practice Address - Country:US
Practice Address - Phone:978-534-6116
Practice Address - Fax:978-534-3294
Is Sole Proprietor?:No
Enumeration Date:2007-09-12
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN/NP276156363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1301071OtherGROUP #