Healthcare Provider Details

I. General information

NPI: 1639015894
Provider Name (Legal Business Name): PENNY W. GALLOWAY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2026
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2195 SAN FILIPPO DR SE
PALM BAY FL
32909-7206
US

IV. Provider business mailing address

2195 SAN FILIPPO DR SE
PALM BAY FL
32909-7206
US

V. Phone/Fax

Practice location:
  • Phone: 321-616-0809
  • Fax: 321-616-0809
Mailing address:
  • Phone: 321-616-0809
  • Fax: 321-616-0809

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMH28855
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: