Provider Demographics
NPI:1578862793
Name:GALLANT, JEAN M (OTA)
Entity Type:Individual
Prefix:MISS
First Name:JEAN
Middle Name:M
Last Name:GALLANT
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 STAGECOACH LN
Mailing Address - Street 2:
Mailing Address - City:WINDHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04062-5150
Mailing Address - Country:US
Mailing Address - Phone:207-892-9924
Mailing Address - Fax:
Practice Address - Street 1:67 PINE POINT RD
Practice Address - Street 2:
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074-8813
Practice Address - Country:US
Practice Address - Phone:207-883-2468
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-28
Last Update Date:2011-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOA1739224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant