Provider Demographics
NPI:1164077087
Name:GALLARDO, PAUL KURT (OTR/L)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:KURT
Last Name:GALLARDO
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 SERPENTINE DR E
Mailing Address - Street 2:
Mailing Address - City:BAYVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08721-3050
Mailing Address - Country:US
Mailing Address - Phone:732-674-9050
Mailing Address - Fax:
Practice Address - Street 1:70 SERPENTINE DR E
Practice Address - Street 2:
Practice Address - City:BAYVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08721-3050
Practice Address - Country:US
Practice Address - Phone:732-674-9050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-07
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR00884100225X00000X
NY023606225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist