Provider Demographics
NPI:1386687861
Name:GALLOWAY, KAREN SUE (OTR)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:SUE
Last Name:GALLOWAY
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5124 S SPRINKLE RD
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-2055
Mailing Address - Country:US
Mailing Address - Phone:269-381-1880
Mailing Address - Fax:269-381-1850
Practice Address - Street 1:5124 S SPRINKLE RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-2055
Practice Address - Country:US
Practice Address - Phone:269-381-1880
Practice Address - Fax:269-381-1850
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAA438994225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4719045Medicaid
MIP08850001Medicare ID - Type UnspecifiedOT