Healthcare Provider Details

I. General information

NPI: 1497265953
Provider Name (Legal Business Name): MELISSA ANN GALLUP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2017
Last Update Date: 09/10/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HWY 264 MPP 388
POLACCA AZ
86042
US

IV. Provider business mailing address

74 BUNNER ST
OSWEGO NY
13126-3357
US

V. Phone/Fax

Practice location:
  • Phone: 928-737-6187
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number093725
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: