Healthcare Provider Details

I. General information

NPI: 1033639034
Provider Name (Legal Business Name): SANFORD I PLISKIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2017
Last Update Date: 06/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

153 SUMMER STREET
PROVIDENCE RI
02903
US

IV. Provider business mailing address

153 SUMMER ST
PROVIDENCE RI
02903-4011
US

V. Phone/Fax

Practice location:
  • Phone: 401-276-4300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMHC00838
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: