Provider Demographics
NPI:1508500356
Name:GALLAGHER, GRADY MATTHEW
Entity type:Individual
Prefix:MR
First Name:GRADY
Middle Name:MATTHEW
Last Name:GALLAGHER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8414 FARM ROAD
Mailing Address - Street 2:STE 180 #1024
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89131-8007
Mailing Address - Country:US
Mailing Address - Phone:202-489-1403
Mailing Address - Fax:
Practice Address - Street 1:9930 O LOUGHLIN MANOR AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89149-1299
Practice Address - Country:US
Practice Address - Phone:202-489-1403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-26
Last Update Date:2025-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPY1229103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty