Provider Demographics
NPI:1548301070
Name:ANGELILLO, SUSANNA P (LMHC)
Entity type:Individual
Prefix:
First Name:SUSANNA
Middle Name:P
Last Name:ANGELILLO
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:226 FLINT AVE
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02910-2514
Mailing Address - Country:US
Mailing Address - Phone:401-942-4375
Mailing Address - Fax:401-942-4375
Practice Address - Street 1:2 REGENCY PLZ STE 20
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-3152
Practice Address - Country:US
Practice Address - Phone:401-837-1285
Practice Address - Fax:401-942-4375
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2015-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMHC00312101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
32284-1OtherBLUE CROSS/BLUE SHIELD
600052724OtherMAGELLAN
414055OtherBLUE CHIP
RISA65487Medicaid