Provider Demographics
NPI:1093808461
Name:PIETROGALLO, THOMAS S (MSW/LCSW, MBA)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:S
Last Name:PIETROGALLO
Suffix:
Gender:M
Credentials:MSW/LCSW, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3510 BISCAYNE BLVD
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33137-3840
Mailing Address - Country:US
Mailing Address - Phone:305-576-1234
Mailing Address - Fax:305-571-2020
Practice Address - Street 1:3510 BISCAYNE BLVD
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33137-3840
Practice Address - Country:US
Practice Address - Phone:305-576-1234
Practice Address - Fax:305-571-2020
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-30
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW63301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL765599100Medicaid
FL765599100Medicaid