Provider Demographics
NPI:1134280423
Name:GALLAGHER, MARK RICHARD (LICSW)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:RICHARD
Last Name:GALLAGHER
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 SPENCER AVE
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02144-2611
Mailing Address - Country:US
Mailing Address - Phone:617-623-5397
Mailing Address - Fax:
Practice Address - Street 1:173 CHELSEA ST
Practice Address - Street 2:TRI CITY MENTAL HEALTH CENTER
Practice Address - City:EVERETT
Practice Address - State:MA
Practice Address - Zip Code:02149
Practice Address - Country:US
Practice Address - Phone:781-388-6224
Practice Address - Fax:617-387-9768
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10260181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP20183Medicare ID - Type Unspecified