Provider Demographics
NPI:1073171583
Name:GALLANT, RACHEAL DENISE (PTA)
Entity Type:Individual
Prefix:
First Name:RACHEAL
Middle Name:DENISE
Last Name:GALLANT
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:339 E MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:NORTH CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44720-2593
Mailing Address - Country:US
Mailing Address - Phone:330-498-8200
Mailing Address - Fax:
Practice Address - Street 1:129 KELLY MARIE DR
Practice Address - Street 2:
Practice Address - City:PATASKALA
Practice Address - State:OH
Practice Address - Zip Code:43062-8148
Practice Address - Country:US
Practice Address - Phone:903-987-5090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-30
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA.012221225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant