Provider Demographics
NPI:1639327661
Name:CEVALLOS, JORGE (MASTERS)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:
Last Name:CEVALLOS
Suffix:
Gender:M
Credentials:MASTERS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 BEECHWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02860-5402
Mailing Address - Country:US
Mailing Address - Phone:401-722-5573
Mailing Address - Fax:401-724-9735
Practice Address - Street 1:160 BEECHWOOD AVE
Practice Address - Street 2:
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02860-5402
Practice Address - Country:US
Practice Address - Phone:401-722-5573
Practice Address - Fax:401-724-9735
Is Sole Proprietor?:No
Enumeration Date:2008-09-03
Last Update Date:2008-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIGH57134Medicaid