Provider Demographics
NPI:1497292825
Name:GALLAGHER, CARL J (LADC)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:J
Last Name:GALLAGHER
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 313
Mailing Address - Street 2:
Mailing Address - City:CARIBOU
Mailing Address - State:ME
Mailing Address - Zip Code:04736-0313
Mailing Address - Country:US
Mailing Address - Phone:207-493-1700
Mailing Address - Fax:
Practice Address - Street 1:2 ARMCO AVE
Practice Address - Street 2:
Practice Address - City:CARIBOU
Practice Address - State:ME
Practice Address - Zip Code:04736
Practice Address - Country:US
Practice Address - Phone:207-493-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-24
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC6602101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MECAC6134OtherBOARD OF ALCOHOL & DRUG COUNSELORS