Healthcare Provider Details

I. General information

NPI: 1124053897
Provider Name (Legal Business Name): JERRY FRANK MAIELLO JR. LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JERRY FRANK MAIELLO JR. LCSW

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

331 USHERS ROAD NORTHWAY 10 PROFESSIONAL PARK
BALLSTON LAKE NY
12019
US

IV. Provider business mailing address

PO. BOX 873 CLIFTON PARK
NEW YORK NY
12065-5013
US

V. Phone/Fax

Practice location:
  • Phone: 518-371-1122
  • Fax: 518-437-6565
Mailing address:
  • Phone: 518-371-1122
  • Fax: 518-437-6565

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberPR024915-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: