Provider Demographics
NPI:1356437396
Name:ROBERTS, LISA IV
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:ROBERTS
Suffix:IV
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:637 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WOONSOCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02895-5758
Mailing Address - Country:US
Mailing Address - Phone:401-769-3186
Mailing Address - Fax:
Practice Address - Street 1:55 JOHN A CUMMINGS WAY
Practice Address - Street 2:
Practice Address - City:WOONSOCKET
Practice Address - State:RI
Practice Address - Zip Code:02895-3247
Practice Address - Country:US
Practice Address - Phone:401-235-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPC396101Y00000X
RICDP00537101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
RILR56123Medicaid