Provider Demographics
NPI:1356556294
Name:MULLERVY, AMY (LISCW)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:
Last Name:MULLERVY
Suffix:
Gender:F
Credentials:LISCW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:390 TOLL GATE RD
Mailing Address - Street 2:STE. K 104
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-4326
Mailing Address - Country:US
Mailing Address - Phone:401-739-4969
Mailing Address - Fax:401-739-5158
Practice Address - Street 1:390 TOLL GATE RD
Practice Address - Street 2:STE. K 104
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886-4326
Practice Address - Country:US
Practice Address - Phone:401-739-4969
Practice Address - Fax:401-739-5158
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RILSW003401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIAM52558Medicaid
RI1070770OtherBEACON HEALTH STRATEGIES
RI3229-8OtherBLUE CROSS