Provider Demographics
NPI:1063645604
Name:GALLO, CANDACE MICHELLE (OTR/L)
Entity Type:Individual
Prefix:MS
First Name:CANDACE
Middle Name:MICHELLE
Last Name:GALLO
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:CANDACE
Other - Middle Name:
Other - Last Name:HICKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2000 E. EDGEWOOD DR.
Mailing Address - Street 2:SUITE 114
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33803
Mailing Address - Country:US
Mailing Address - Phone:863-606-5948
Mailing Address - Fax:863-937-9224
Practice Address - Street 1:2000 E. EDGEWOOD DR.
Practice Address - Street 2:SUITE 114
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803
Practice Address - Country:US
Practice Address - Phone:863-606-5948
Practice Address - Fax:863-937-9224
Is Sole Proprietor?:No
Enumeration Date:2009-08-31
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT16594225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist