Provider Demographics
NPI:1972755163
Name:GERRY, MATHEW (SW-C)
Entity Type:Individual
Prefix:
First Name:MATHEW
Middle Name:
Last Name:GERRY
Suffix:
Gender:M
Credentials:SW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78 ATLANTIC PL
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-2316
Mailing Address - Country:US
Mailing Address - Phone:207-842-6556
Mailing Address - Fax:207-842-7773
Practice Address - Street 1:12 UNION ST
Practice Address - Street 2:
Practice Address - City:ROCKLAND
Practice Address - State:ME
Practice Address - Zip Code:04841-2739
Practice Address - Country:US
Practice Address - Phone:207-701-4477
Practice Address - Fax:207-701-4485
Is Sole Proprietor?:No
Enumeration Date:2008-10-21
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELSX11661104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME433041299Medicaid