Provider Demographics
NPI:1164898326
Name:GALON, MAE THERESE
Entity Type:Individual
Prefix:
First Name:MAE THERESE
Middle Name:
Last Name:GALON
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 1:6442 WOODBINE ST
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11385-4654
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6442 WOODBINE ST
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NY
Practice Address - Zip Code:11385-4654
Practice Address - Country:US
Practice Address - Phone:518-278-2995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-11
Last Update Date:2015-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031117-1225100000X
CA42045225100000X
CT009213225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist