Provider Demographics
NPI:1023371457
Name:GALLENTINE, HEATHER KAYE
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:KAYE
Last Name:GALLENTINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1442 5TH ST SE
Mailing Address - Street 2:
Mailing Address - City:NEW PHILADELPHIA
Mailing Address - State:OH
Mailing Address - Zip Code:44663-9301
Mailing Address - Country:US
Mailing Address - Phone:208-610-2778
Mailing Address - Fax:
Practice Address - Street 1:1433 5TH ST NW
Practice Address - Street 2:
Practice Address - City:NEW PHILADELPHIA
Practice Address - State:OH
Practice Address - Zip Code:44663-1223
Practice Address - Country:US
Practice Address - Phone:330-343-8171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-20
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID101YM0800X
OH172V00000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No172V00000XOther Service ProvidersCommunity Health WorkerGroup - Multi-Specialty