Provider Demographics
NPI:1639162423
Name:GALLAGHER, MARY (PT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:GALLAGHER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1422 MONTEREY ST
Mailing Address - Street 2:SUITE C-102
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-2944
Mailing Address - Country:US
Mailing Address - Phone:805-543-5100
Mailing Address - Fax:805-543-5106
Practice Address - Street 1:1422 MONTEREY ST
Practice Address - Street 2:SUITE C-102
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-2944
Practice Address - Country:US
Practice Address - Phone:805-543-5100
Practice Address - Fax:805-543-5106
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 17433225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT 17433OtherPHYSICAL THERAPY LICENSE