Provider Demographics
NPI:1730196403
Name:ISON, ELIZABETH BOGARDUS (LICSW SOCIAL WORKER)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:BOGARDUS
Last Name:ISON
Suffix:
Gender:F
Credentials:LICSW SOCIAL WORKER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 NORTH ROAD
Mailing Address - Street 2:
Mailing Address - City:SOUTH KINGSTOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02879
Mailing Address - Country:US
Mailing Address - Phone:401-782-2896
Mailing Address - Fax:401-789-3748
Practice Address - Street 1:24 SALT POND ROAD
Practice Address - Street 2:STE D4
Practice Address - City:WAKEFIELD
Practice Address - State:RI
Practice Address - Zip Code:02879
Practice Address - Country:US
Practice Address - Phone:401-789-3694
Practice Address - Fax:401-789-3748
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW01309104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI263186OtherRI BLUE CROSS
RIEI41628Medicaid