Provider Demographics
NPI:1275728362
Name:GALLUP, KATHRYN COLLEEN (LCSW)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:COLLEEN
Last Name:GALLUP
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:COLLEEN
Other - Last Name:LINDSEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10 N. MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:NY
Mailing Address - Zip Code:13045
Mailing Address - Country:US
Mailing Address - Phone:607-753-0234
Mailing Address - Fax:607-753-0286
Practice Address - Street 1:10 N. MAIN ST
Practice Address - Street 2:
Practice Address - City:CORTLAND
Practice Address - State:NY
Practice Address - Zip Code:13045
Practice Address - Country:US
Practice Address - Phone:607-753-0234
Practice Address - Fax:607-753-0286
Is Sole Proprietor?:No
Enumeration Date:2007-09-11
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY079520101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1336163963Medicaid
NYJ400068003Medicare UPIN