Provider Demographics
NPI:1639129877
Name:DILIBERO, MARY R (PCNS)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:R
Last Name:DILIBERO
Suffix:
Gender:F
Credentials:PCNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 174
Mailing Address - Street 2:
Mailing Address - City:FOSTER
Mailing Address - State:RI
Mailing Address - Zip Code:02825
Mailing Address - Country:US
Mailing Address - Phone:401-359-5130
Mailing Address - Fax:401-397-6428
Practice Address - Street 1:400 BALD HILL RD
Practice Address - Street 2:SUITE 510
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886
Practice Address - Country:US
Practice Address - Phone:401-732-3637
Practice Address - Fax:701-732-2875
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001427163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT4169406Medicaid
CT890000507Medicare ID - Type Unspecified
CT4169406Medicaid