Provider Demographics
NPI:1639836117
Name:DMITRY MEYERSON, PH. D., LLC
Entity Type:Organization
Organization Name:DMITRY MEYERSON, PH. D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DMITRY
Authorized Official - Middle Name:
Authorized Official - Last Name:MEYERSON
Authorized Official - Suffix:
Authorized Official - Credentials:PH D
Authorized Official - Phone:401-329-2210
Mailing Address - Street 1:177 AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02889-1046
Mailing Address - Country:US
Mailing Address - Phone:401-329-2210
Mailing Address - Fax:401-340-1052
Practice Address - Street 1:177 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02889-1046
Practice Address - Country:US
Practice Address - Phone:401-329-2210
Practice Address - Fax:401-340-1052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-19
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIRI-1972033827Medicaid