Healthcare Provider Details

I. General information

NPI: 1750652269
Provider Name (Legal Business Name): SCOTT MATHEW BOIALLIS LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2012
Last Update Date: 01/07/2020
Certification Date: 01/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 VEAZEY DR
BUTNER NC
27509-1668
US

IV. Provider business mailing address

300 VEAZEY DR
BUTNER NC
27509-1668
US

V. Phone/Fax

Practice location:
  • Phone: 919-764-7102
  • Fax:
Mailing address:
  • Phone: 919-764-5630
  • Fax: 919-764-5231

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC008920
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number084072
License Number StateNY

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: