Provider Demographics
NPI:1609084102
Name:PELLICIO, WILLIAM J (LICSW)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:J
Last Name:PELLICIO
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:273 PRAIRIE AVE
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905-2331
Mailing Address - Country:US
Mailing Address - Phone:401-273-7059
Mailing Address - Fax:
Practice Address - Street 1:273 PRAIRIE AVE
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02905-2331
Practice Address - Country:US
Practice Address - Phone:401-273-7059
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW002141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIWP11143Medicaid
RIWP11143Medicaid