Healthcare Provider Details

I. General information

NPI: 1962870519
Provider Name (Legal Business Name): MR. SAMUEL JOHN GALLAGHER-STEVENS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2015
Last Update Date: 09/18/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 BOREL AVE
SAN MATEO CA
94402-3522
US

IV. Provider business mailing address

1410 MARSHALL STREET
SAN MATEO CA
94401
US

V. Phone/Fax

Practice location:
  • Phone: 650-393-8922
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: