Provider Demographics
NPI:1336297472
Name:GILLOOLY, MICHAEL H (LCSW-C)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:H
Last Name:GILLOOLY
Suffix:
Gender:M
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1538 CHAPMAN RD
Mailing Address - Street 2:
Mailing Address - City:CROFTON
Mailing Address - State:MD
Mailing Address - Zip Code:21114-3100
Mailing Address - Country:US
Mailing Address - Phone:301-261-3574
Mailing Address - Fax:410-721-3436
Practice Address - Street 1:1538 CHAPMAN RD
Practice Address - Street 2:
Practice Address - City:CROFTON
Practice Address - State:MD
Practice Address - Zip Code:21114-3100
Practice Address - Country:US
Practice Address - Phone:301-261-3574
Practice Address - Fax:410-721-3436
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2014-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD050281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD076639OtherVALUE OPTIONS