Provider Demographics
NPI:1497292627
Name:GALLUP, ANNEMARIE LOUISE (CECP)
Entity Type:Individual
Prefix:MS
First Name:ANNEMARIE
Middle Name:LOUISE
Last Name:GALLUP
Suffix:
Gender:F
Credentials:CECP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:955 CARRILLO DR STE 105
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-5400
Mailing Address - Country:US
Mailing Address - Phone:707-364-9019
Mailing Address - Fax:
Practice Address - Street 1:955 CARRILLO DR STE 105
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5400
Practice Address - Country:US
Practice Address - Phone:707-364-9019
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-25
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician