Healthcare Provider Details

I. General information

NPI: 1932525292
Provider Name (Legal Business Name): THAI LYNN GALLO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2014
Last Update Date: 03/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 S E ST
SANTA ROSA CA
95404-4709
US

IV. Provider business mailing address

201 S E ST
SANTA ROSA CA
95404-4709
US

V. Phone/Fax

Practice location:
  • Phone: 707-573-6960
  • Fax: 707-573-6961
Mailing address:
  • Phone: 707-573-6960
  • Fax: 707-573-6961

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: