Provider Demographics
NPI:1922086081
Name:THEBARGE, RONALD W (PHD)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:W
Last Name:THEBARGE
Suffix:
Gender:M
Credentials:PHD
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 3238
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-3238
Mailing Address - Country:US
Mailing Address - Phone:866-689-8862
Mailing Address - Fax:
Practice Address - Street 1:1 HOPPIN ST
Practice Address - Street 2:CORO CENTER, 3RD FLOOR
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4141
Practice Address - Country:US
Practice Address - Phone:401-793-8770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-08
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPS00437103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI407727OtherBLUECHIP
RI30534-9OtherBCBS RI
RI007056453Medicare PIN
RI30534-9OtherBCBS RI