Provider Demographics
NPI:1467814913
Name:GALLEGOS, MOLLY (MA, OTR/L)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:GALLEGOS
Suffix:
Gender:F
Credentials:MA, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1906 W FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605
Mailing Address - Country:US
Mailing Address - Phone:208-385-3680
Mailing Address - Fax:208-385-3681
Practice Address - Street 1:1906 FAIRVIEW AVE STE 330
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-5425
Practice Address - Country:US
Practice Address - Phone:208-385-3680
Practice Address - Fax:208-385-3681
Is Sole Proprietor?:No
Enumeration Date:2016-03-23
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1574225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist