Provider Demographics
NPI:1417255175
Name:GALLAS, JOHN J (MA, PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:J
Last Name:GALLAS
Suffix:
Gender:M
Credentials:MA, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 KANE ST
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:PA
Mailing Address - Zip Code:18407-3055
Mailing Address - Country:US
Mailing Address - Phone:570-341-4735
Mailing Address - Fax:
Practice Address - Street 1:22 KANE ST
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:PA
Practice Address - Zip Code:18407-3055
Practice Address - Country:US
Practice Address - Phone:570-341-4735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-04
Last Update Date:2011-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS006988L103G00000X, 103TB0200X, 103TC0700X, 103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAGA 612619Medicare PIN