Provider Demographics
NPI:1740419902
Name:GARGALA, THERESA R (MA, LLPC)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:R
Last Name:GARGALA
Suffix:
Gender:F
Credentials:MA, LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 E 8TH ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-3575
Mailing Address - Country:US
Mailing Address - Phone:616-510-5515
Mailing Address - Fax:
Practice Address - Street 1:44 E 8TH ST
Practice Address - Street 2:SUITE 200
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-3575
Practice Address - Country:US
Practice Address - Phone:616-510-5515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-09
Last Update Date:2009-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401011392101YM0800X, 101YP2500X, 102L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst