Provider Demographics
NPI:1508544412
Name:GALLOWAY, MILDRED
Entity Type:Individual
Prefix:
First Name:MILDRED
Middle Name:
Last Name:GALLOWAY
Suffix:
Gender:F
Credentials:
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 361193
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43236-1193
Mailing Address - Country:US
Mailing Address - Phone:614-902-7364
Mailing Address - Fax:
Practice Address - Street 1:2770 E MAIN ST STE 28
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43209-3519
Practice Address - Country:US
Practice Address - Phone:614-902-8978
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-10
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health