Provider Demographics
NPI:1952866162
Name:GALLUP, SAMUEL ALEXANDER
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:ALEXANDER
Last Name:GALLUP
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21204 SE GOLDEN MARKET LN
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-3651
Mailing Address - Country:US
Mailing Address - Phone:518-727-4404
Mailing Address - Fax:
Practice Address - Street 1:19800 VILLAGE OFFICE CT STE 104
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-1813
Practice Address - Country:US
Practice Address - Phone:541-480-2570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-01
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician