Provider Demographics
NPI:1518116201
Name:GALLAGHER, MARYELLEN (CAC)
Entity Type:Individual
Prefix:
First Name:MARYELLEN
Middle Name:
Last Name:GALLAGHER
Suffix:
Gender:F
Credentials:CAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 DIVISION ST.
Mailing Address - Street 2:GRIFFIN HOSPITAL
Mailing Address - City:DERBY
Mailing Address - State:CT
Mailing Address - Zip Code:06418
Mailing Address - Country:US
Mailing Address - Phone:203-732-7550
Mailing Address - Fax:203-732-1550
Practice Address - Street 1:130 DIVISION ST.
Practice Address - Street 2:GRIFFIN HOSPITAL
Practice Address - City:DERBY
Practice Address - State:CT
Practice Address - Zip Code:06418
Practice Address - Country:US
Practice Address - Phone:203-732-7550
Practice Address - Fax:203-732-1550
Is Sole Proprietor?:No
Enumeration Date:2008-09-17
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)