Provider Demographics
NPI:1962867234
Name:GALLOSA, JANNETH
Entity Type:Individual
Prefix:
First Name:JANNETH
Middle Name:
Last Name:GALLOSA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 TICHENOR ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07102-3315
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:201 LOWER NOTCH RD # A-3
Practice Address - Street 2:
Practice Address - City:LITTLE FALLS
Practice Address - State:NJ
Practice Address - Zip Code:07424-1802
Practice Address - Country:US
Practice Address - Phone:973-837-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-30
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR00432500225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist