Provider Demographics
NPI:1659611085
Name:RETALLACK, GARTH RAYMOND
Entity Type:Individual
Prefix:MR
First Name:GARTH
Middle Name:RAYMOND
Last Name:RETALLACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:346 ELLIOTT ST
Mailing Address - Street 2:
Mailing Address - City:BEVERLY
Mailing Address - State:MA
Mailing Address - Zip Code:01915-2347
Mailing Address - Country:US
Mailing Address - Phone:978-697-2744
Mailing Address - Fax:
Practice Address - Street 1:346 ELLIOTT ST
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-2347
Practice Address - Country:US
Practice Address - Phone:978-697-2744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-21
Last Update Date:2013-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor