Provider Demographics
NPI:1124231360
Name:VIRGILIO, BETHANY (LICSW)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:VIRGILIO
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 1:4705A OLD POST RD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02813-1819
Mailing Address - Country:US
Mailing Address - Phone:401-364-7705
Mailing Address - Fax:401-364-9104
Practice Address - Street 1:70 KENYON AVE UNIT 211
Practice Address - Street 2:
Practice Address - City:WAKEFIELD
Practice Address - State:RI
Practice Address - Zip Code:02879-4241
Practice Address - Country:US
Practice Address - Phone:401-788-1276
Practice Address - Fax:401-788-1514
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW021991041C0700X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI001309701OtherMEDICARE PTAN
RIBG5938Medicaid
RIBG59338Medicaid