Healthcare Provider Details

I. General information

NPI: 1336648047
Provider Name (Legal Business Name): JAMES RANDOL GILOOLY PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/08/2018
Last Update Date: 11/22/2024
Certification Date: 11/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13 BAY AVE. UNIT C
OLD ORCHARD BEACH ME
04064
US

IV. Provider business mailing address

13 BAY AVE UNIT C
OLD ORCHARD BEACH ME
04064-2609
US

V. Phone/Fax

Practice location:
  • Phone: 207-205-2074
  • Fax:
Mailing address:
  • Phone: 207-205-2074
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC17038
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2014012232
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS2597
License Number StateME

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: