Provider Demographics
NPI:1144287491
Name:BOMFORD, JOHN D (LISW)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:D
Last Name:BOMFORD
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:249 ROOSEVELT AVE
Mailing Address - Street 2:STE 205
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02860
Mailing Address - Country:US
Mailing Address - Phone:401-724-8400
Mailing Address - Fax:701-365-1100
Practice Address - Street 1:1516 ATWOOD AVE
Practice Address - Street 2:
Practice Address - City:JOHNSTON
Practice Address - State:RI
Practice Address - Zip Code:02919
Practice Address - Country:US
Practice Address - Phone:401-553-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2007-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker