Provider Demographics
NPI:1316186216
Name:GALLEGOS, AMY ELIZABETH (DPT)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:ELIZABETH
Last Name:GALLEGOS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 E GRAND RIVER AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48116-1551
Mailing Address - Country:US
Mailing Address - Phone:810-360-0806
Mailing Address - Fax:844-809-2246
Practice Address - Street 1:455 E GRAND RIVER AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48116-1551
Practice Address - Country:US
Practice Address - Phone:810-360-0806
Practice Address - Fax:844-809-2246
Is Sole Proprietor?:No
Enumeration Date:2009-02-17
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501011484225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP01343534OtherRAILROAD MEDICARE
MIN69750023Medicare PIN
MIP01343534OtherRAILROAD MEDICARE