Provider Demographics
NPI:1811079502
Name:EAST BAY COUNSLING CENTER, INC..
Entity type:Organization
Organization Name:EAST BAY COUNSLING CENTER, INC..
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:NELSON
Authorized Official - Last Name:GAVALYA. MD
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:401-728-3400
Mailing Address - Street 1:77 BEECHWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02860-5409
Mailing Address - Country:US
Mailing Address - Phone:401-728-3400
Mailing Address - Fax:401-724-3990
Practice Address - Street 1:77 BEECHWOOD AVE
Practice Address - Street 2:
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02860-5409
Practice Address - Country:US
Practice Address - Phone:401-728-3400
Practice Address - Fax:401-724-3990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2010-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIRIMD43232084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI30095-1OtherBCBS
RI269000501Medicare ID - Type Unspecified