Provider Demographics
NPI:1376634345
Name:GALLAHER, RICHARD BALLOU JR (PHD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:BALLOU
Last Name:GALLAHER
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:513 THAIN ROAD
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-4140
Mailing Address - Country:US
Mailing Address - Phone:208-743-0150
Mailing Address - Fax:208-743-5358
Practice Address - Street 1:513 THAIN ROAD
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-4140
Practice Address - Country:US
Practice Address - Phone:208-743-0150
Practice Address - Fax:208-743-5358
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY-202154103T00000X
WAPY00000815103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010147148OtherREGENCE BLUESHIELD
WA041256289Medicaid
ID550867358OtherGENERAL INSURANCE NUMBER
IDY0929OtherIDAHO BLUE CROSS
ID806984800Medicaid
ID1684737Medicare PIN