Basic Information
| Provider Information | |||||||||
| NPI: | 1912151945 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | QUALLIOTINE | ||||||||
| FirstName: | CAILIN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PSYD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GIBBONS | ||||||||
| OtherFirstName: | CAILIN | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1236 MAIN ST STE 301 | ||||||||
| Address2: | |||||||||
| City: | HOLYOKE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010405370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1236 MAIN ST STE 301 | ||||||||
| Address2: | |||||||||
| City: | HOLYOKE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010405370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2067215170 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2008 | ||||||||
| LastUpdateDate: | 11/20/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 11207 | MA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical | 101YM0800X | 10907 | MA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.