Provider Demographics
NPI:1225197965
Name:GALLANTY, JAMES RICHARD (PT)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:RICHARD
Last Name:GALLANTY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 9451
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96158
Mailing Address - Country:US
Mailing Address - Phone:530-541-3481
Mailing Address - Fax:
Practice Address - Street 1:2877 LAKE TAHOE BLVD
Practice Address - Street 2:SUITE D
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150
Practice Address - Country:US
Practice Address - Phone:530-541-7133
Practice Address - Fax:530-541-7132
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT9548225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA620361OtherBLUE SHIELD
CA620361OtherBLUE SHIELD