Provider Demographics
NPI:1750177762
Name:GALLAGHER, KELLY R (DSP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:R
Last Name:GALLAGHER
Suffix:
Gender:
Credentials:DSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 RIVERFRONT AVE
Mailing Address - Street 2:
Mailing Address - City:PAULSBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08066-2202
Mailing Address - Country:US
Mailing Address - Phone:856-443-3803
Mailing Address - Fax:
Practice Address - Street 1:49 RIVERFRONT AVE
Practice Address - Street 2:
Practice Address - City:PAULSBORO
Practice Address - State:NJ
Practice Address - Zip Code:08066-2202
Practice Address - Country:US
Practice Address - Phone:856-443-3803
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-16
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services