Provider Demographics
NPI:1952705287
Name:GALLUB, JOHN R (PHD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:GALLUB
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10608 JAMAICA AVE
Mailing Address - Street 2:GALLUB SERVICES FOR TBI
Mailing Address - City:RICHMOND HILL
Mailing Address - State:NY
Mailing Address - Zip Code:11418-2015
Mailing Address - Country:US
Mailing Address - Phone:718-850-5553
Mailing Address - Fax:
Practice Address - Street 1:10608 JAMAICA AVE
Practice Address - Street 2:GALLUB SERVICES FOR TBI
Practice Address - City:RICHMOND HILL
Practice Address - State:NY
Practice Address - Zip Code:11418-2015
Practice Address - Country:US
Practice Address - Phone:718-850-5553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-15
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011773103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist