Provider Demographics
NPI:1346895513
Name:GALLOWAY, MIRANDA JUSTINE
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:JUSTINE
Last Name:GALLOWAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 CORPORATE DR STE 301
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22554-4889
Mailing Address - Country:US
Mailing Address - Phone:540-225-1020
Mailing Address - Fax:
Practice Address - Street 1:8701 MAITLAND SUMMIT BLVD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32810-5915
Practice Address - Country:US
Practice Address - Phone:407-574-4629
Practice Address - Fax:407-965-4480
Is Sole Proprietor?:No
Enumeration Date:2019-08-05
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician