Provider Demographics
NPI:1033610365
Name:GALKULAME, MEDHANKARA THERO
Entity Type:Individual
Prefix:
First Name:MEDHANKARA
Middle Name:THERO
Last Name:GALKULAME
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2780 W LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92801-6333
Mailing Address - Country:US
Mailing Address - Phone:714-864-7908
Mailing Address - Fax:
Practice Address - Street 1:771 W ORANGETHORPE AVE
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92832-2806
Practice Address - Country:US
Practice Address - Phone:714-879-0929
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-22
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13944101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)