Provider Demographics
NPI:1336648047
Name:GILOOLY, JAMES RANDOL (LCSW)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:RANDOL
Last Name:GILOOLY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 BAY AVE UNIT C
Mailing Address - Street 2:
Mailing Address - City:OLD ORCHARD BEACH
Mailing Address - State:ME
Mailing Address - Zip Code:04064-2609
Mailing Address - Country:US
Mailing Address - Phone:207-205-2074
Mailing Address - Fax:
Practice Address - Street 1:13 BAY AVE.
Practice Address - Street 2:UNIT C
Practice Address - City:OLD ORCHARD BEACH
Practice Address - State:ME
Practice Address - Zip Code:04064
Practice Address - Country:US
Practice Address - Phone:207-205-2074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-08
Last Update Date:2018-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC170381041C0700X
MO20140122321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical