Provider Demographics
NPI:1639226798
Name:GALLAGHER, MARY M
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:M
Last Name:GALLAGHER
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:MARY
Other - Middle Name:M
Other - Last Name:GALLAGHER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:8 OHAYO DR
Mailing Address - Street 2:
Mailing Address - City:WEST HURLEY
Mailing Address - State:NY
Mailing Address - Zip Code:12491-5622
Mailing Address - Country:US
Mailing Address - Phone:845-417-1482
Mailing Address - Fax:
Practice Address - Street 1:8 OHAYO DR
Practice Address - Street 2:
Practice Address - City:WEST HURLEY
Practice Address - State:NY
Practice Address - Zip Code:12491-5622
Practice Address - Country:US
Practice Address - Phone:845-417-1482
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01987103T00000X
NY018766103TC0700X
NY018766-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY30013775OtherMEDICARE PTANA
MD633200500Medicaid
MD633200500Medicaid
NYA400123819Medicare PIN