Healthcare Provider Details

I. General information

NPI: 1043644156
Provider Name (Legal Business Name): MR. GERARD F EYSSALLENNE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2013
Last Update Date: 08/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99 CHURCH ST
LOWELL MA
01852-2621
US

IV. Provider business mailing address

24 KEVIN ST
TEWKSBURY MA
01876-3937
US

V. Phone/Fax

Practice location:
  • Phone: 978-458-6282
  • Fax: 978-441-9826
Mailing address:
  • Phone: 978-851-9181
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: