Provider Demographics
NPI:1689886194
Name:SOUTHCOAST PSYCHOLOGY,INC
Entity Type:Organization
Organization Name:SOUTHCOAST PSYCHOLOGY,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:PETROUSKI
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:508-644-1210
Mailing Address - Street 1:P.O. BOX 642
Mailing Address - Street 2:
Mailing Address - City:ASSONET
Mailing Address - State:MA
Mailing Address - Zip Code:02702-1446
Mailing Address - Country:US
Mailing Address - Phone:508-644-1210
Mailing Address - Fax:508-644-1210
Practice Address - Street 1:154 WATERMAN STREET
Practice Address - Street 2:3RD FLOOR WEST
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906
Practice Address - Country:US
Practice Address - Phone:401-241-2059
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPS00719103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI#SS11558Medicaid