Provider Demographics
NPI:1124181243
Name:PENDERGAST, MICHAEL COLE (MSW, LICSW, ACSW)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:COLE
Last Name:PENDERGAST
Suffix:
Gender:M
Credentials:MSW, LICSW, ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 899
Mailing Address - Street 2:SOUTH SHORE MENTAL HEALTH CENTER
Mailing Address - City:CHARLESTOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02813
Mailing Address - Country:US
Mailing Address - Phone:401-364-7705
Mailing Address - Fax:
Practice Address - Street 1:4705A OLD POST RD
Practice Address - Street 2:
Practice Address - City:CHARLESTOWN
Practice Address - State:RI
Practice Address - Zip Code:02813-1819
Practice Address - Country:US
Practice Address - Phone:401-364-7705
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW013381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIMP34524Medicaid
RI27303-7OtherBLUE CROSS BLUE SHIELD
RI408142OtherBLUE CHIP
RIMP34524Medicaid