Provider Demographics
NPI:1134400369
Name:GALLAGHER, JON D (LADC)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:D
Last Name:GALLAGHER
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:ME
Mailing Address - Zip Code:04330-4705
Mailing Address - Country:US
Mailing Address - Phone:207-458-7780
Mailing Address - Fax:
Practice Address - Street 1:67 EUSTIS PKWY
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:ME
Practice Address - Zip Code:04901-5173
Practice Address - Country:US
Practice Address - Phone:207-873-2136
Practice Address - Fax:207-872-4522
Is Sole Proprietor?:No
Enumeration Date:2011-09-01
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC4988101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)