Provider Demographics
NPI:1154069045
Name:PELOQUIN, SAMUEL WALLACE (LICSW)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:WALLACE
Last Name:PELOQUIN
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 1:825 PONTIAC AVE APT 15303
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02910-5944
Mailing Address - Country:US
Mailing Address - Phone:401-499-1043
Mailing Address - Fax:
Practice Address - Street 1:825 PONTIAC AVE APT 15303
Practice Address - Street 2:
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02910-5944
Practice Address - Country:US
Practice Address - Phone:401-499-1043
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-22
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW03231104100000X
RIISW0232311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker