Provider Demographics
NPI:1124053897
Name:MAIELLO, JERRY FRANK JR (LCSW)
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:FRANK
Last Name:MAIELLO
Suffix:JR
Gender:M
Credentials:LCSW
Other - Prefix:MR
Other - First Name:JERRY
Other - Middle Name:FRANK
Other - Last Name:MAIELLO
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO. BOX 873
Mailing Address - Street 2:CLIFTON PARK
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:12065-5013
Mailing Address - Country:US
Mailing Address - Phone:518-371-1122
Mailing Address - Fax:518-437-6565
Practice Address - Street 1:331 USHERS ROAD
Practice Address - Street 2:NORTHWAY 10 PROFESSIONAL PARK
Practice Address - City:BALLSTON LAKE
Practice Address - State:NY
Practice Address - Zip Code:12019
Practice Address - Country:US
Practice Address - Phone:518-371-1122
Practice Address - Fax:518-437-6565
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYPR024915-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical