Healthcare Provider Details

I. General information

NPI: 1194470773
Provider Name (Legal Business Name): KEVIN GALLAGHER LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2022
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1080 EMELINE AVE
SANTA CRUZ CA
95060-1966
US

IV. Provider business mailing address

1080 EMELINE AVE
SANTA CRUZ CA
95060-1966
US

V. Phone/Fax

Practice location:
  • Phone: 831-454-4100
  • Fax:
Mailing address:
  • Phone: 831-454-4100
  • Fax: 831-454-4488

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number139621
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: