MEDICARE: COLLABORATIVE FOR BEHAVIORAL HEALTH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	CDP00146	RI
2	1041C0700X	Clinical Social Worker	ISW00719	RI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1154348803
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLLABORATIVE FOR BEHAVIORAL HEALTH

Provider Business Mailing Address
First Line	:	34 2ND ST
Second Line	:
City	:	SWANSEA
State	:	MA
Zip	:	02777-3203
Country	:	US
Telephone Number	:	508-324-5282
Fax Number	:	401-245-5395

Provider Business Practice Location Address
First Line	:	654 METACOM AVE
Second Line	:
City	:	WARREN
State	:	RI
Zip	:	02885-2300
Country	:	US
Telephone Number	:	401-245-5395
Fax Number	:	401-245-5395

Authorized Official
Title or Position	:	CLINCAL DIRECTOR
Name	:	MS. DENISE MARIE FRAGOZA
Credential	:	MSW,LICSW,LCDP
Telephone Number	:	401-245-5395

Provider Enumeration Date	:	07/17/2006
Last Update Date	:	07/09/2008

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