Provider Demographics
NPI:1356398648
Name:GALLEGRA, ELIZABETH A (OT)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:A
Last Name:GALLEGRA
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67-76 BOOTH ST
Mailing Address - Street 2:APT 7I
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375
Mailing Address - Country:US
Mailing Address - Phone:718-897-2758
Mailing Address - Fax:516-488-8818
Practice Address - Street 1:1999 MARCUS AVE
Practice Address - Street 2:SUITE M15
Practice Address - City:LAKE SUCCESS
Practice Address - State:NY
Practice Address - Zip Code:11042-1013
Practice Address - Country:US
Practice Address - Phone:516-488-8808
Practice Address - Fax:516-488-8818
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY01455-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ4MJ10Medicare PIN