Provider Demographics
NPI:1750621413
Name:GALLAGHER-ROSS, SUSAN BERNADETTE (PHD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:BERNADETTE
Last Name:GALLAGHER-ROSS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4710 NW 2ND AVE
Mailing Address - Street 2:SUITE# 104
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33431-4155
Mailing Address - Country:US
Mailing Address - Phone:561-372-5500
Mailing Address - Fax:
Practice Address - Street 1:4710 NW 2ND AVE
Practice Address - Street 2:SUITE# 104
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33431-4155
Practice Address - Country:US
Practice Address - Phone:561-372-5500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-18
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019990103TC0700X
FLPY 8823103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical