Provider Demographics
NPI:1063511764
Name:QUEALY, MAURA B (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MAURA
Middle Name:B
Last Name:QUEALY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 STONY CT
Mailing Address - Street 2:
Mailing Address - City:HAMPTON BAYS
Mailing Address - State:NY
Mailing Address - Zip Code:11946-2232
Mailing Address - Country:US
Mailing Address - Phone:631-728-2786
Mailing Address - Fax:631-728-2786
Practice Address - Street 1:5 STONY CT
Practice Address - Street 2:
Practice Address - City:HAMPTON BAYS
Practice Address - State:NY
Practice Address - Zip Code:11946-2232
Practice Address - Country:US
Practice Address - Phone:631-728-2786
Practice Address - Fax:631-728-2786
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR053333-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02420542Medicaid
NYNT0132Medicare ID - Type Unspecified