Provider Demographics
NPI:1417716689
Name:GALLAGHER, MARC
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:
Last Name:GALLAGHER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:523 ARLINGTON ST
Mailing Address - Street 2:
Mailing Address - City:TAMAQUA
Mailing Address - State:PA
Mailing Address - Zip Code:18252-2105
Mailing Address - Country:US
Mailing Address - Phone:570-778-6582
Mailing Address - Fax:
Practice Address - Street 1:166 MARIAN AVE
Practice Address - Street 2:
Practice Address - City:TAMAQUA
Practice Address - State:PA
Practice Address - Zip Code:18252-4755
Practice Address - Country:US
Practice Address - Phone:570-467-3335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-18
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART0049482255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer