Provider Demographics
NPI:1477603900
Name:GALLO, MICHAEL STEPHEN (OT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:STEPHEN
Last Name:GALLO
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17233 N HOLMES BLVD
Mailing Address - Street 2:STE 1650
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85053-2018
Mailing Address - Country:US
Mailing Address - Phone:602-547-1836
Mailing Address - Fax:602-467-8677
Practice Address - Street 1:17233 N HOLMES BLVD
Practice Address - Street 2:STE 1650
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85053-2018
Practice Address - Country:US
Practice Address - Phone:602-547-1836
Practice Address - Fax:602-467-8677
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3456225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ950510Medicaid
AZ103395Medicare ID - Type Unspecified