Provider Demographics
NPI:1144234246
Name:ROMAN, MATTHEW J (LICSW)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:J
Last Name:ROMAN
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 PROSSER TRL
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02813-2840
Mailing Address - Country:US
Mailing Address - Phone:401-331-1350
Mailing Address - Fax:401-277-3366
Practice Address - Street 1:55 HOPE ST
Practice Address - Street 2:C/O FAMILY SERVICE OF RHODE ISLAND
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-2001
Practice Address - Country:US
Practice Address - Phone:401-331-1350
Practice Address - Fax:401-277-3366
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW013491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI30315-8OtherBLUE CROSS/SHIELD
478002OtherVALUE OPTIONS
RI408143OtherBLUE CHIP
UBHOther6232362
NHPOther1021740 GROUP
RIMR33981Medicaid