Provider Demographics
NPI:1750652269
Name:BOIALLIS, SCOTT MATHEW (LCSW)
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:MATHEW
Last Name:BOIALLIS
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 1:300 VEAZEY DR
Mailing Address - Street 2:
Mailing Address - City:BUTNER
Mailing Address - State:NC
Mailing Address - Zip Code:27509-1668
Mailing Address - Country:US
Mailing Address - Phone:919-764-5630
Mailing Address - Fax:919-764-5231
Practice Address - Street 1:300 VEAZEY DR
Practice Address - Street 2:
Practice Address - City:BUTNER
Practice Address - State:NC
Practice Address - Zip Code:27509-1668
Practice Address - Country:US
Practice Address - Phone:919-764-7102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-16
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0089201041C0700X
NY084072104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker