Provider Demographics
NPI:1245461490
Name:GALLAGHER, NICOLE W (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:W
Last Name:GALLAGHER
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:263 FARMINGTON AVENUE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06030-8082
Mailing Address - Country:US
Mailing Address - Phone:860-487-9200
Mailing Address - Fax:860-487-9222
Practice Address - Street 1:149 SYLVAN ST
Practice Address - Street 2:
Practice Address - City:DANVERS
Practice Address - State:MA
Practice Address - Zip Code:01923-3564
Practice Address - Country:US
Practice Address - Phone:978-774-7570
Practice Address - Fax:978-777-8547
Is Sole Proprietor?:No
Enumeration Date:2009-08-06
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6347235Z00000X
CT004217235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist