Provider Demographics
NPI:1104838978
Name:DUSSAULT, LORETTE (LICSW)
Entity Type:Individual
Prefix:
First Name:LORETTE
Middle Name:
Last Name:DUSSAULT
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:528 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02904-5757
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:55 S BROW ST
Practice Address - Street 2:
Practice Address - City:EAST PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02914-4433
Practice Address - Country:US
Practice Address - Phone:401-434-4748
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2009-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW000621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI1104847946OtherTHE PROVIDENCE CENTER NPI
RI62-19452OtherUNITED BEHAVIORAL HEALTH
RILD05243Medicaid
RI406328OtherBLUE CHIP
RI3443-4OtherBLUE CROSS