Provider Demographics
NPI:1356483176
Name:GALLAGHER, SUSAN ANNE (MED, LPC)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:ANNE
Last Name:GALLAGHER
Suffix:
Gender:F
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5008 POWDER RIVER RD
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-4129
Mailing Address - Country:US
Mailing Address - Phone:512-799-2696
Mailing Address - Fax:
Practice Address - Street 1:4201 MARATHON BLVD STE 206
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78756-3409
Practice Address - Country:US
Practice Address - Phone:512-799-2696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18184101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX7061LCOtherBLUE CROSS BLUE SHIELD