Provider Demographics
NPI:1083382543
Name:GALLOWAY, KASEY KEEGAN
Entity Type:Individual
Prefix:
First Name:KASEY
Middle Name:KEEGAN
Last Name:GALLOWAY
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 1:12557 RAVENWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CHARDON
Mailing Address - State:OH
Mailing Address - Zip Code:44024-9009
Mailing Address - Country:US
Mailing Address - Phone:440-285-3568
Mailing Address - Fax:
Practice Address - Street 1:12557 RAVENWOOD DR
Practice Address - Street 2:
Practice Address - City:CHARDON
Practice Address - State:OH
Practice Address - Zip Code:44024-9009
Practice Address - Country:US
Practice Address - Phone:440-285-3568
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-31
Last Update Date:2022-09-27
Deactivation Date:2022-07-26
Deactivation Code:
Reactivation Date:2022-09-21
Provider Licenses
StateLicense IDTaxonomies
OH104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2871101Medicaid