Provider Demographics
NPI:1245798925
Name:PALLISTER, BRIAN
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:
Last Name:PALLISTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:74 MIANTONOMO DR
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02888-5316
Mailing Address - Country:US
Mailing Address - Phone:401-426-9876
Mailing Address - Fax:
Practice Address - Street 1:205 HALLENE RD UNIT 102
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886-2451
Practice Address - Country:US
Practice Address - Phone:401-426-9876
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-12
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RICDP00783101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)