Provider Demographics
NPI:1194860775
Name:GALLUP, VIRGINIA M (MA,SLP)
Entity Type:Individual
Prefix:MS
First Name:VIRGINIA
Middle Name:M
Last Name:GALLUP
Suffix:
Gender:F
Credentials:MA,SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11577 W MULE DEER CT
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-2511
Mailing Address - Country:US
Mailing Address - Phone:602-399-2278
Mailing Address - Fax:
Practice Address - Street 1:11577 W MULE DEER CT
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-2511
Practice Address - Country:US
Practice Address - Phone:602-399-2278
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2010-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPL 5389235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist