Provider Demographics
NPI:1164175329
Name:GALLAGHER, SHIRLEY
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:
Last Name:GALLAGHER
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 1:708 INTRACOASTAL DR
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33304-3621
Mailing Address - Country:US
Mailing Address - Phone:954-817-6107
Mailing Address - Fax:954-530-7988
Practice Address - Street 1:708 INTRACOASTAL DR
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33304-3621
Practice Address - Country:US
Practice Address - Phone:954-817-6107
Practice Address - Fax:954-530-7988
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-28
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities