Provider Demographics
NPI:1669798070
Name:GALLO, PHYLLIS CONSALVO (SLP)
Entity type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:CONSALVO
Last Name:GALLO
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 CIRCLE PLACE
Mailing Address - Street 2:BOX 224
Mailing Address - City:SMALLWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:12778
Mailing Address - Country:US
Mailing Address - Phone:845-583-5024
Mailing Address - Fax:
Practice Address - Street 1:4 CIRCLE PL
Practice Address - Street 2:
Practice Address - City:SMALLWOOD
Practice Address - State:NY
Practice Address - Zip Code:12778-0224
Practice Address - Country:US
Practice Address - Phone:845-583-5024
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-09
Last Update Date:2010-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010378-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist