Provider Demographics
NPI:1982323358
Name:SQUARE ONE GJM
Entity Type:Organization
Organization Name:SQUARE ONE GJM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:AMY
Authorized Official - Middle Name:N
Authorized Official - Last Name:SISSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:740-441-5809
Mailing Address - Street 1:PO BOX 272
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-0272
Mailing Address - Country:US
Mailing Address - Phone:740-441-5809
Mailing Address - Fax:
Practice Address - Street 1:49 OLIVE ST
Practice Address - Street 2:
Practice Address - City:GALLIPOLIS
Practice Address - State:OH
Practice Address - Zip Code:45631-1632
Practice Address - Country:US
Practice Address - Phone:740-441-5809
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-26
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty