Provider Demographics
NPI:1467820530
Name:GALLAGHER, MARK
Entity Type:Individual
Prefix:
First Name:MARK
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 1:2100 CREEKVIEW DR
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43040-8391
Mailing Address - Country:US
Mailing Address - Phone:937-578-7119
Mailing Address - Fax:
Practice Address - Street 1:2100 CREEKVIEW DR
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43040-8391
Practice Address - Country:US
Practice Address - Phone:937-578-7119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-08
Last Update Date:2015-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH3151561103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool