Healthcare Provider Details

I. General information

NPI: 1902955974
Provider Name (Legal Business Name): SERGIO DE CONNO LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 BALD HILL RD SUITE 510
WARWICK RI
02886-1617
US

IV. Provider business mailing address

400 BALD HILL RD SUITE 510
WARWICK RI
02886-1617
US

V. Phone/Fax

Practice location:
  • Phone: 401-732-3637
  • Fax: 401-732-2875
Mailing address:
  • Phone: 401-732-3637
  • Fax: 401-732-2875

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberISW00718
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: