Provider Demographics
NPI:1528001476
Name:STOCKWELL, SAMUEL R (PHD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:R
Last Name:STOCKWELL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 HOLLEY ST
Mailing Address - Street 2:
Mailing Address - City:WAKEFIELD
Mailing Address - State:RI
Mailing Address - Zip Code:02879-3300
Mailing Address - Country:US
Mailing Address - Phone:401-789-0963
Mailing Address - Fax:401-789-9063
Practice Address - Street 1:30 HOLLEY ST
Practice Address - Street 2:
Practice Address - City:WAKEFIELD
Practice Address - State:RI
Practice Address - Zip Code:02879-3300
Practice Address - Country:US
Practice Address - Phone:401-789-0963
Practice Address - Fax:401-789-9063
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI224103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9009224Medicaid
RI9224-7OtherBCBS
RI108714OtherTRICARE
RI61-08837OtherUBH
RI1020690OtherBEACON