Provider Demographics
NPI:1780838755
Name:GALLO, SUSANNE (PYSD)
Entity Type:Individual
Prefix:
First Name:SUSANNE
Middle Name:
Last Name:GALLO
Suffix:
Gender:F
Credentials:PYSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:590 EL DORADO AVE APT 113
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94611-5069
Mailing Address - Country:US
Mailing Address - Phone:510-388-7339
Mailing Address - Fax:
Practice Address - Street 1:1600 CALIFORNA DR.
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95696
Practice Address - Country:US
Practice Address - Phone:707-448-6841
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-04
Last Update Date:2008-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20512103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical