1760965479 NPI number — JACQUELYN MAYO GEORGALLAS LICSW

Table of content: JACQUELYN MAYO GEORGALLAS LICSW (NPI 1760965479)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760965479 NPI number — JACQUELYN MAYO GEORGALLAS LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GEORGALLAS
Provider First Name:
JACQUELYN
Provider Middle Name:
MAYO
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LICSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MAYO
Provider Other First Name:
JACQUELYN
Provider Other Middle Name:
MARY
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1760965479
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/14/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
165 PELHAM RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALEM
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03079-2855
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
603-475-3771
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
173 S RIVER RD STE 3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BEDFORD
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03110-6930
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-934-9444
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/09/2018

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:  2935 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 000224046 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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