MEDICARE: NORTH ROAD PSYCHIATRY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1215540042
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTH ROAD PSYCHIATRY LLC

Provider Business Mailing Address
First Line	:	23 NORTH RD STE A11
Second Line	:
City	:	PEACE DALE
State	:	RI
Zip	:	02879-8108
Country	:	US
Telephone Number	:	401-447-1777
Fax Number	:

Provider Business Practice Location Address
First Line	:	23 NORTH RD STE A11
Second Line	:
City	:	PEACE DALE
State	:	RI
Zip	:	02879-8108
Country	:	US
Telephone Number	:	401-447-1777
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	GLORIA MARY MAZZA
Credential	:	APRN
Telephone Number	:	401-447-1777

Provider Enumeration Date	:	08/31/2020
Last Update Date	:	08/31/2020

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