Provider Demographics
NPI:1356410724
Name:MACCOLL, GREGORY J (LCSW)
Entity type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:J
Last Name:MACCOLL
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 1:110-20 71 AVENUE
Mailing Address - Street 2:PROFESSIONAL SUITE
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-4553
Mailing Address - Country:US
Mailing Address - Phone:718-805-1660
Mailing Address - Fax:
Practice Address - Street 1:110-20 71 AVENUE
Practice Address - Street 2:PROFESSIONAL SUITE
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-4553
Practice Address - Country:US
Practice Address - Phone:718-805-1660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYPR0212661104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02798Medicare ID - Type Unspecified