Provider Demographics
NPI:1639515919
Name:GALLO, ANTONIA (MOTR/L)
Entity Type:Individual
Prefix:
First Name:ANTONIA
Middle Name:
Last Name:GALLO
Suffix:
Gender:F
Credentials:MOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15409 BONDESSON ST
Mailing Address - Street 2:
Mailing Address - City:BENNINGTON
Mailing Address - State:NE
Mailing Address - Zip Code:68007-7484
Mailing Address - Country:US
Mailing Address - Phone:563-212-0166
Mailing Address - Fax:
Practice Address - Street 1:2242 WRIGHT ST
Practice Address - Street 2:
Practice Address - City:BLAIR
Practice Address - State:NE
Practice Address - Zip Code:68008-1148
Practice Address - Country:US
Practice Address - Phone:563-212-0166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-14
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225X00000X
IA2187225X00000X
NE1601225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist