Provider Demographics
NPI:1912089558
Name:GALLAGHER, LADEMA JEAN (MSN)
Entity Type:Individual
Prefix:
First Name:LADEMA
Middle Name:JEAN
Last Name:GALLAGHER
Suffix:
Gender:F
Credentials:MSN
Other - Prefix:
Other - First Name:LADEMA
Other - Middle Name:JEAN
Other - Last Name:POPPA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2605 N LEBANON ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:IN
Mailing Address - Zip Code:46052-1476
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2605 N LEBANON ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:IN
Practice Address - Zip Code:46052-1476
Practice Address - Country:US
Practice Address - Phone:765-485-8000
Practice Address - Fax:765-485-8719
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN70000028A364SP0809X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201020090Medicaid