Provider Demographics
NPI:1619155058
Name:GALLAGHER, LEONARD JOSEPH II (PHYD)
Entity Type:Individual
Prefix:MR
First Name:LEONARD
Middle Name:JOSEPH
Last Name:GALLAGHER
Suffix:II
Gender:M
Credentials:PHYD
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 722
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:MI
Mailing Address - Zip Code:49230
Mailing Address - Country:US
Mailing Address - Phone:517-414-0697
Mailing Address - Fax:
Practice Address - Street 1:451 MARSHALL ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:MI
Practice Address - Zip Code:49230
Practice Address - Country:US
Practice Address - Phone:517-414-0697
Practice Address - Fax:517-938-5914
Is Sole Proprietor?:No
Enumeration Date:2008-02-07
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301012470103T00000X
MILG012470103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOP29630Medicare PIN