Provider Demographics
NPI:1790284933
Name:GALLAHUE, MARTHA JEAN (LP)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:JEAN
Last Name:GALLAHUE
Suffix:
Gender:F
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 W 95TH ST # IMEDSO
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-6689
Mailing Address - Country:US
Mailing Address - Phone:212-932-7809
Mailing Address - Fax:
Practice Address - Street 1:165 W 95TH ST # IMEDSO
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-6689
Practice Address - Country:US
Practice Address - Phone:212-932-7809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-02
Last Update Date:2018-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000236102L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000236OtherNEW YORK STATE