Provider Demographics
NPI:1679198824
Name:GALLITZ, DONNA M
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:M
Last Name:GALLITZ
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 1:14616 REESE BLVD W APT 626
Mailing Address - Street 2:
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28078-0312
Mailing Address - Country:US
Mailing Address - Phone:908-256-4755
Mailing Address - Fax:
Practice Address - Street 1:421 FAYETTEVILLE ST STE 1100
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27601-3000
Practice Address - Country:US
Practice Address - Phone:877-418-2978
Practice Address - Fax:866-500-2186
Is Sole Proprietor?:No
Enumeration Date:2020-06-13
Last Update Date:2020-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician