Provider Demographics
NPI:1548779366
Name:PHOENIX, MADRONE BAYAN (LICSW)
Entity type:Individual
Prefix:
First Name:MADRONE
Middle Name:BAYAN
Last Name:PHOENIX
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02881-0005
Mailing Address - Country:US
Mailing Address - Phone:401-441-5834
Mailing Address - Fax:
Practice Address - Street 1:1 RICHMOND SQ STE 333C
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-5139
Practice Address - Country:US
Practice Address - Phone:401-441-5834
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-25
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RICSW020551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty