Provider Demographics
NPI:1679877906
Name:LEVESQUE, KELLY (LCDP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:LEVESQUE
Suffix:
Gender:F
Credentials:LCDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:166 PAWTUCKET AVE
Mailing Address - Street 2:
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02860-3811
Mailing Address - Country:US
Mailing Address - Phone:401-722-4644
Mailing Address - Fax:401-722-5039
Practice Address - Street 1:166 PAWTUCKET AVE
Practice Address - Street 2:
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02860-3811
Practice Address - Country:US
Practice Address - Phone:401-722-4644
Practice Address - Fax:401-722-5039
Is Sole Proprietor?:No
Enumeration Date:2010-12-30
Last Update Date:2010-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RICDP00429101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIGH57134Medicaid