Healthcare Provider Details

I. General information

NPI: 1437581758
Provider Name (Legal Business Name): AMYSUE GALLAGHER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2013
Last Update Date: 12/01/2021
Certification Date: 11/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

841 PRUDENTIAL DR STE 1900
JACKSONVILLE FL
32207-8373
US

IV. Provider business mailing address

910 N JEFFERSON ST
JACKSONVILLE FL
32209-6810
US

V. Phone/Fax

Practice location:
  • Phone: 904-633-9020
  • Fax:
Mailing address:
  • Phone: 904-360-7022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW12155
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: