Provider Demographics
NPI:1629170899
Name:CREQUE, GAIL R (LCSW)
Entity Type:Individual
Prefix:MS
First Name:GAIL
Middle Name:R
Last Name:CREQUE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 ARTHURS WAY
Mailing Address - Street 2:
Mailing Address - City:PASCOAG
Mailing Address - State:RI
Mailing Address - Zip Code:02859-3509
Mailing Address - Country:US
Mailing Address - Phone:401-273-7100
Mailing Address - Fax:401-457-3371
Practice Address - Street 1:830 CHALKSTONE AVENUE
Practice Address - Street 2:VA MEDICAL CENTER
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02908
Practice Address - Country:US
Practice Address - Phone:401-273-7100
Practice Address - Fax:401-457-3371
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RICSW00536104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker