Provider Demographics
NPI:1346522430
Name:DICOSTANZO, COLLEEN A
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:A
Last Name:DICOSTANZO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:A
Other - Last Name:DICOSTANZO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSW
Mailing Address - Street 1:64 ANOKA AVE
Mailing Address - Street 2:
Mailing Address - City:BARRINGTON
Mailing Address - State:RI
Mailing Address - Zip Code:02806-3506
Mailing Address - Country:US
Mailing Address - Phone:401-241-6094
Mailing Address - Fax:
Practice Address - Street 1:1061 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:NEW BEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02740-6728
Practice Address - Country:US
Practice Address - Phone:508-996-8572
Practice Address - Fax:508-996-8628
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-14
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI82119231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical