Healthcare Provider Details

I. General information

NPI: 1790316990
Provider Name (Legal Business Name): DAKOTA STEVEN GALLIMORE LPCA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2020
Last Update Date: 04/03/2020
Certification Date: 04/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4835 POPLAR LEVEL RD STE 110
LOUISVILLE KY
40213-2906
US

IV. Provider business mailing address

4835 POPLAR LEVEL RD STE 110
LOUISVILLE KY
40213-2906
US

V. Phone/Fax

Practice location:
  • Phone: 831-277-1176
  • Fax: 502-631-9660
Mailing address:
  • Phone: 855-591-0092
  • Fax: 502-631-9660

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number261448
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: