Healthcare Provider Details

I. General information

NPI: 1740744200
Provider Name (Legal Business Name): REYNALD PAUL GALLOSA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2019
Last Update Date: 06/10/2025
Certification Date: 06/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4031 W DAYTON ST
MCHENRY IL
60050-8377
US

IV. Provider business mailing address

4031 W DAYTON ST
MCHENRY IL
60050-8377
US

V. Phone/Fax

Practice location:
  • Phone: 816-344-1230
  • Fax:
Mailing address:
  • Phone: 816-344-1230
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.016732
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: