Provider Demographics
NPI:1265099022
Name:GALLAGHER, MICHELLE (PHD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:GALLAGHER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:SHELLEY
Other - Middle Name:
Other - Last Name:GALLAGHER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:429 ROOSEVELT AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-3144
Mailing Address - Country:US
Mailing Address - Phone:917-685-2284
Mailing Address - Fax:
Practice Address - Street 1:UPSTATE MEDICAL UNIVERSITY
Practice Address - Street 2:750 E. ADAMS ST.
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210
Practice Address - Country:US
Practice Address - Phone:315-464-3446
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-28
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013537-01103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY013537-01OtherLIMITED PERMIT TO PRACTICE PSYCHOLOGY IN NEW YORK STATE