Provider Demographics
NPI:1225123599
Name:DANIELSON, GALEN EUGENE (DPT)
Entity Type:Individual
Prefix:MR
First Name:GALEN
Middle Name:EUGENE
Last Name:DANIELSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1560 S CAROL ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-1839
Mailing Address - Country:US
Mailing Address - Phone:208-288-1155
Mailing Address - Fax:208-288-0424
Practice Address - Street 1:5520 N. EAGLE ROAD
Practice Address - Street 2:SUITE 102
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-0998
Practice Address - Country:US
Practice Address - Phone:208-938-5255
Practice Address - Fax:208-938-5545
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-1534174400000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1653148Medicare PIN