Provider Demographics
NPI:1043644156
Name:EYSSALLENNE, GERARD F
Entity Type:Individual
Prefix:MR
First Name:GERARD
Middle Name:F
Last Name:EYSSALLENNE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 KEVIN ST
Mailing Address - Street 2:
Mailing Address - City:TEWKSBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01876-3937
Mailing Address - Country:US
Mailing Address - Phone:978-851-9181
Mailing Address - Fax:
Practice Address - Street 1:99 CHURCH ST
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01852-2621
Practice Address - Country:US
Practice Address - Phone:978-458-6282
Practice Address - Fax:978-441-9826
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-26
Last Update Date:2013-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1305638Medicaid