Provider Demographics
NPI:1831644319
Name:GALLEGOS, KOURTNEY MARIE (MSW)
Entity Type:Individual
Prefix:MRS
First Name:KOURTNEY
Middle Name:MARIE
Last Name:GALLEGOS
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:MISS
Other - First Name:KOURTNEY
Other - Middle Name:MARIE
Other - Last Name:VAN ZANT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:645 S ROGERS ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-2353
Mailing Address - Country:US
Mailing Address - Phone:812-339-1691
Mailing Address - Fax:
Practice Address - Street 1:421 S WALNUT ST STE 200
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47305-2484
Practice Address - Country:US
Practice Address - Phone:765-288-1790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-24
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
IN34008725A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker