Provider Demographics
NPI:1407033210
Name:MONGEAU, BETTY (LICSW)
Entity Type:Individual
Prefix:
First Name:BETTY
Middle Name:
Last Name:MONGEAU
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 1:75 SOCKANOSSET CROSS RD
Mailing Address - Street 2:SUITE 208B
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02920-5558
Mailing Address - Country:US
Mailing Address - Phone:401-559-5537
Mailing Address - Fax:401-615-5172
Practice Address - Street 1:75 SOCKANOSSET CROSSROAD
Practice Address - Street 2:
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02920
Practice Address - Country:US
Practice Address - Phone:401-785-0371
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-23
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW016661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIISW01666OtherSOCIAL WORK LICENSE