Healthcare Provider Details

I. General information

NPI: 1942070602
Provider Name (Legal Business Name): VANESSA ALLEGRA DIAMBOU MOULAMBI LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2024
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 BACON ST
PAWTUCKET RI
02860-5542
US

IV. Provider business mailing address

208 FLYNN AVE STE 3J
BURLINGTON VT
05401-5420
US

V. Phone/Fax

Practice location:
  • Phone: 401-722-3560
  • Fax: 401-722-3593
Mailing address:
  • Phone: 802-488-6934
  • Fax: 802-488-6919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW04039
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number097-0135266
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: