Provider Demographics
NPI:1083762256
Name:GALLAGHER, MARY ANNE (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY ANNE
Middle Name:
Last Name:GALLAGHER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2550 HONOLULU AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CA
Mailing Address - Zip Code:91020-1859
Mailing Address - Country:US
Mailing Address - Phone:818-243-5674
Mailing Address - Fax:
Practice Address - Street 1:2550 HONOLULU AVE STE 103
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CA
Practice Address - Zip Code:91020-1859
Practice Address - Country:US
Practice Address - Phone:818-243-5674
Practice Address - Fax:818-957-5860
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-06
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34415106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist