Provider Demographics
NPI:1912186891
Name:GALLIVAN, PATRICK
Entity Type:Individual
Prefix:MR
First Name:PATRICK
Middle Name:
Last Name:GALLIVAN
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 1:17 HOMESTEAD AVE
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:MA
Mailing Address - Zip Code:01501-2038
Mailing Address - Country:US
Mailing Address - Phone:508-523-8727
Mailing Address - Fax:
Practice Address - Street 1:340 MAIN ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01608-1604
Practice Address - Country:US
Practice Address - Phone:508-523-8727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-29
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health