Provider Demographics
NPI:1417466053
Name:GALLACE, BRIDGET DARA (MSED)
Entity Type:Individual
Prefix:MRS
First Name:BRIDGET
Middle Name:DARA
Last Name:GALLACE
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:BRIDGET
Other - Middle Name:DARA
Other - Last Name:AMANN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSED
Mailing Address - Street 1:8 EAST AVE
Mailing Address - Street 2:
Mailing Address - City:GLEN COVE
Mailing Address - State:NY
Mailing Address - Zip Code:11542-3917
Mailing Address - Country:US
Mailing Address - Phone:631-672-9043
Mailing Address - Fax:
Practice Address - Street 1:8 EAST AVE
Practice Address - Street 2:
Practice Address - City:GLEN COVE
Practice Address - State:NY
Practice Address - Zip Code:11542-3917
Practice Address - Country:US
Practice Address - Phone:631-672-9043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency