Provider Demographics
NPI:1780805283
Name:TRISVAN, MARCEL A (LCDP)
Entity type:Individual
Prefix:MR
First Name:MARCEL
Middle Name:A
Last Name:TRISVAN
Suffix:
Gender:M
Credentials:LCDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 NELLIE ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02904
Mailing Address - Country:US
Mailing Address - Phone:401-270-0000
Mailing Address - Fax:
Practice Address - Street 1:CODAC PROVIDENCE
Practice Address - Street 2:349 HUNTINGTON AVE
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02909
Practice Address - Country:US
Practice Address - Phone:401-942-1450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RILCDP-352101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)