Provider Demographics
NPI:1790118503
Name:GALLAGHER, BRENDAN (PT, DPT)
Entity Type:Individual
Prefix:
First Name:BRENDAN
Middle Name:
Last Name:GALLAGHER
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 W LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:ROCKAWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:07866-1002
Mailing Address - Country:US
Mailing Address - Phone:973-841-0877
Mailing Address - Fax:
Practice Address - Street 1:138 W LAKE SHORE DR
Practice Address - Street 2:
Practice Address - City:ROCKAWAY
Practice Address - State:NJ
Practice Address - Zip Code:07866
Practice Address - Country:US
Practice Address - Phone:973-841-0877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-15
Last Update Date:2018-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01614700225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist