Healthcare Provider Details

I. General information

NPI: 1083611032
Provider Name (Legal Business Name): JERRY WILLIAM MACCAULEY LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/06/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 CEDAR RD
CHESAPEAKE VA
23322-5566
US

IV. Provider business mailing address

411 CEDAR RD
CHESAPEAKE VA
23322-5566
US

V. Phone/Fax

Practice location:
  • Phone: 757-548-8848
  • Fax: 757-549-1347
Mailing address:
  • Phone: 757-548-8848
  • Fax: 757-549-1347

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904002572
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: