Healthcare Provider Details

I. General information

NPI: 1508403874
Provider Name (Legal Business Name): DAVID GALLAGHER LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2019
Last Update Date: 12/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

82 MAIN ST
WINDSOR LOCKS CT
06096-2325
US

IV. Provider business mailing address

82 MAIN ST
WINDSOR LOCKS CT
06096-2325
US

V. Phone/Fax

Practice location:
  • Phone: 860-254-5127
  • Fax: 860-310-4235
Mailing address:
  • Phone: 860-254-5127
  • Fax: 860-310-4235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number009349
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: