=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285900761
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DEBORAH C MATSON, MSW INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/28/2012
-----------------------------------------------------
Last Update Date | 03/28/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 331 BROADWAY
-----------------------------------------------------
City | PROVIDENCE
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02909-1101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-455-0799
-----------------------------------------------------
Fax | 401-454-2773
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 88 WINDWARD LN
-----------------------------------------------------
City | BRISTOL
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02809-1551
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-455-0799
-----------------------------------------------------
Fax | 401-454-2773
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MS. DEBORAH CONSTANCE MATSON
-----------------------------------------------------
Credential | MSW
-----------------------------------------------------
Telephone | 401-455-0799
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | ISW00335
-----------------------------------------------------
License Number State | RI
-----------------------------------------------------