| Name: | MedOp Behavioral Health Associates of Rhode Island, P.C. |
| Jurisdiction: | Rhode Island |
| Entity type: | Professional Service Corporation |
| Status: | Dissolved |
| Date of Organization in Rhode Island: | 16 Oct 2006 (18 years ago) |
| Date of Dissolution: | 28 Feb 2023 (2 years ago) |
| Date of Status Change: | 28 Feb 2023 (2 years ago) |
| Identification Number: | 000159067 |
| Principal Address: | 1480 BOSTON POST ROAD, OLD SAYBROOK, CT, 06475, USA |
| Purpose: | BEHAVIORAL HEALTH SERVICES |
| NAICS: | 621330 - Offices of Mental Health Practitioners (except Physicians) |
| Fictitious names: |
LifeStance Health (trading name, 2021-06-29 - 2021-11-08) |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| 1013129220 | 2007-05-03 | 2016-08-30 | 55 HATCHETTS HILL RD, OLD LYME, CT, 063711534, US | 222 JEFFERSON BLVD, SUITE 200, WARWICK, RI, 028883847, US | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| Phone | +1 800-370-3651 |
| Fax | 8605100020 |
Authorized person
| Name | DONNA DOOLEY |
| Role | CFO |
| Phone | 8003703651 |
Taxonomy
| Taxonomy Code | 103TC0700X - Clinical Psychologist |
| Is Primary | No |
| Taxonomy Code | 1041C0700X - Clinical Social Worker |
| Is Primary | No |
| Taxonomy Code | 163WP0809X - Adult Psychiatric/Mental Health Registered Nurse |
| Is Primary | No |
| Taxonomy Code | 164W00000X - Licensed Practical Nurse |
| Is Primary | No |
| Taxonomy Code | 2084N0400X - Neurology Physician |
| Is Primary | No |
| Taxonomy Code | 2084N0600X - Clinical Neurophysiology Physician |
| Is Primary | No |
| Taxonomy Code | 2084P0800X - Psychiatry Physician |
| Is Primary | Yes |
| Taxonomy Code | 2084P0805X - Geriatric Psychiatry Physician |
| Is Primary | No |
| Taxonomy Code | 363A00000X - Physician Assistant |
| Is Primary | No |
| Taxonomy Code | 363LA2200X - Adult Health Nurse Practitioner |
| Is Primary | No |
| Taxonomy Code | 363LG0600X - Gerontology Nurse Practitioner |
| Is Primary | No |
| Taxonomy Code | 364SG0600X - Gerontology Clinical Nurse Specialist |
| Is Primary | No |
| Taxonomy Code | 364SP0808X - Psychiatric/Mental Health Clinical Nurse Specialist |
| Is Primary | No |
| Taxonomy Code | 364SP0809X - Adult Psychiatric/Mental Health Clinical Nurse Specialist |
| Is Primary | No |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | MB68062 |
| State | RI |
| Name | Role | Address |
|---|---|---|
| CORPORATION SERVICE COMPANY | Agent | 222 JEFFERSON BOULEVARD SUITE 200, WARWICK, RI, 02888, USA |
| Name | Role | Address |
|---|---|---|
| ANISHA PATEL-DUNN | PRESIDENT | 10655 NE 4TH ST, STE 901 BELLEVUE, WA 98004 USA |
| Name | Role | Address |
|---|---|---|
| RYAN PARDO | SECRETARY | 10655 NE 4TH ST, STE 901 BELLEVUE, WA 98004 USA |
| Number | Name | File Date |
|---|---|---|
| 202329556750 | Articles of Dissolution | 2023-02-28 |
| 202221201730 | Statement of Change of Registered/Resident Agent | 2022-07-13 |
| 202211525730 | Annual Report | 2022-02-24 |
| 202104798900 | Statement of Abandonment of Use of Fictitious Business Name | 2021-11-07 |
| 202198809010 | Fictitious Business Name Statement | 2021-06-29 |
| 202198568160 | Statement of Change of Registered/Resident Agent | 2021-06-23 |
| 202191408580 | Annual Report | 2021-02-16 |
| 202033971720 | Annual Report | 2020-02-08 |
| 201987980510 | Annual Report | 2019-03-01 |
| 201859449060 | Annual Report | 2018-03-01 |
Date of last update: 10 Oct 2024
Sources: Rhode Island Department of State
