Healthcare Provider Details

I. General information

NPI: 1639129877
Provider Name (Legal Business Name): MARY R DILIBERO PCNS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 09/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 BALD HILL RD SUITE 510
WARWICK RI
02886
US

IV. Provider business mailing address

PO BOX 174
FOSTER RI
02825
US

V. Phone/Fax

Practice location:
  • Phone: 401-732-3637
  • Fax: 701-732-2875
Mailing address:
  • Phone: 401-359-5130
  • Fax: 401-397-6428

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number001427
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: