1124053897 NPI number — MR. JERRY FRANK MAIELLO JR. LCSW

Table of content: MR. JERRY FRANK MAIELLO JR. LCSW (NPI 1124053897)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124053897 NPI number — MR. JERRY FRANK MAIELLO JR. LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAIELLO
Provider First Name:
JERRY
Provider Middle Name:
FRANK
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
LCSW
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MAIELLO
Provider Other First Name:
JERRY
Provider Other Middle Name:
FRANK
Provider Other Name Prefix Text:
MR.
Provider Other Name Suffix Text:
JR.
Provider Other Credential Text:
LCSW
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1124053897
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO. BOX 873
Provider Second Line Business Mailing Address:
CLIFTON PARK
Provider Business Mailing Address City Name:
NEW YORK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12065-5013
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-371-1122
Provider Business Mailing Address Fax Number:
518-437-6565

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
331 USHERS ROAD
Provider Second Line Business Practice Location Address:
NORTHWAY 10 PROFESSIONAL PARK
Provider Business Practice Location Address City Name:
BALLSTON LAKE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12019
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-371-1122
Provider Business Practice Location Address Fax Number:
518-437-6565
Provider Enumeration Date:
07/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  PR024915-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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