Provider Demographics
NPI:1770913113
Name:GALLAGHER, THEODORE
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:
Last Name:GALLAGHER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 RAFF RD SW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44710-1560
Mailing Address - Country:US
Mailing Address - Phone:330-327-3087
Mailing Address - Fax:
Practice Address - Street 1:400 CAROLYN CT
Practice Address - Street 2:
Practice Address - City:MINERVA
Practice Address - State:OH
Practice Address - Zip Code:44657-8703
Practice Address - Country:US
Practice Address - Phone:330-868-4104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-21
Last Update Date:2013-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH04743224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant