Provider Demographics
NPI:1780768234
Name:PROVIDENCE COMMUNITY ACTION
Entity type:Organization
Organization Name:PROVIDENCE COMMUNITY ACTION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DIGNA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARRERO
Authorized Official - Suffix:
Authorized Official - Credentials:LCDP, RCS
Authorized Official - Phone:401-272-0660
Mailing Address - Street 1:662 HARTFORD AVENUE
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02909
Mailing Address - Country:US
Mailing Address - Phone:401-272-0660
Mailing Address - Fax:401-454-0195
Practice Address - Street 1:662 HARTFORD AVENUE
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02909
Practice Address - Country:US
Practice Address - Phone:401-272-0660
Practice Address - Fax:401-454-0195
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2009-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI615.1251S00000X
251B00000X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIPC12087Medicaid
RI410608OtherBLUE CHIP
RI1021990OtherBEACON
RI303635-5OtherBLUE CROSS