Provider Demographics
NPI:1518479864
Name:GALLAGHER, AMY JEAN (LCSW)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:JEAN
Last Name:GALLAGHER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 MAY FLOWER AVE
Mailing Address - Street 2:
Mailing Address - City:PAWCATUCK
Mailing Address - State:CT
Mailing Address - Zip Code:06379-1913
Mailing Address - Country:US
Mailing Address - Phone:860-608-4023
Mailing Address - Fax:
Practice Address - Street 1:11A STOTT AVE
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-1507
Practice Address - Country:US
Practice Address - Phone:860-823-5350
Practice Address - Fax:860-886-6567
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-26
Last Update Date:2017-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0099361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty