Provider Demographics
NPI:1598302291
Name:PHIPPS-MOORE, SAMANTHA (LCDP)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:PHIPPS-MOORE
Suffix:
Gender:F
Credentials:LCDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 GEORGE ST
Mailing Address - Street 2:
Mailing Address - City:NORTH PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02911-1612
Mailing Address - Country:US
Mailing Address - Phone:401-215-5584
Mailing Address - Fax:
Practice Address - Street 1:530 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-5762
Practice Address - Country:US
Practice Address - Phone:401-453-7618
Practice Address - Fax:401-453-7692
Is Sole Proprietor?:No
Enumeration Date:2019-12-02
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RICDP00823101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)