Provider Demographics
NPI:1275552937
Name:GALLUP, TRICIA (PT)
Entity Type:Individual
Prefix:
First Name:TRICIA
Middle Name:
Last Name:GALLUP
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:PO BOX 2298
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56302-2298
Mailing Address - Country:US
Mailing Address - Phone:320-203-9045
Mailing Address - Fax:320-203-9539
Practice Address - Street 1:35 LAKE ST S
Practice Address - Street 2:STE 600
Practice Address - City:BIG LAKE
Practice Address - State:MN
Practice Address - Zip Code:55309
Practice Address - Country:US
Practice Address - Phone:763-263-6565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6446225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist