Provider Demographics
NPI:1750580734
Name:GALLAGHER, KIMBERLY (PT)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:GALLAGHER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:NAKLICKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:91 CAMDEN ST
Mailing Address - Street 2:STE 401
Mailing Address - City:ROCKLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04841-2421
Mailing Address - Country:US
Mailing Address - Phone:207-593-6682
Mailing Address - Fax:207-593-7149
Practice Address - Street 1:91 CAMDEN ST
Practice Address - Street 2:STE 401
Practice Address - City:ROCKLAND
Practice Address - State:ME
Practice Address - Zip Code:04841-2421
Practice Address - Country:US
Practice Address - Phone:207-593-6682
Practice Address - Fax:207-593-7149
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-11
Last Update Date:2018-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT2629225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME11802104OtherCAQH
ME9096094OtherAETNA
ME9096094OtherAETNA