Provider Demographics
NPI:1689625485
Name:GALLAWAY, JODY A (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JODY
Middle Name:A
Last Name:GALLAWAY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 N 8TH ST
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-4006
Mailing Address - Country:US
Mailing Address - Phone:920-459-3207
Mailing Address - Fax:920-459-4353
Practice Address - Street 1:1011 N 8TH ST
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-4006
Practice Address - Country:US
Practice Address - Phone:920-459-3155
Practice Address - Fax:920-459-4353
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X
WI2319-057103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39134800Medicaid
WI39134800Medicaid