Provider Demographics
NPI:1043529415
Name:GALLUP, SAMANTHA J (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:J
Last Name:GALLUP
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:BALLSTON SPA
Mailing Address - State:NY
Mailing Address - Zip Code:12020-3628
Mailing Address - Country:US
Mailing Address - Phone:518-848-2709
Mailing Address - Fax:
Practice Address - Street 1:2-8 W MAIN ST
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:NY
Practice Address - Zip Code:12095-2308
Practice Address - Country:US
Practice Address - Phone:518-848-0843
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-01
Last Update Date:2010-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0319402251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics