Provider Demographics
NPI:1699394270
Name:GALLAGHER, COLIN J (PHD)
Entity Type:Individual
Prefix:DR
First Name:COLIN
Middle Name:J
Last Name:GALLAGHER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1526 14TH ST STE 109
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-3320
Mailing Address - Country:US
Mailing Address - Phone:323-800-8820
Mailing Address - Fax:
Practice Address - Street 1:1526 14TH ST STE 109
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-3320
Practice Address - Country:US
Practice Address - Phone:323-800-8820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-13
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31739103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA31739OtherPSYCHOLOGIST LICENSE NUMBER