Healthcare Provider Details

I. General information

NPI: 1487942702
Provider Name (Legal Business Name): KELLIANN GALLAGHER DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2011
Last Update Date: 07/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 N MAIN ST
GLASSBORO NJ
08028-1605
US

IV. Provider business mailing address

707 N MAIN ST
GLASSBORO NJ
08028-1605
US

V. Phone/Fax

Practice location:
  • Phone: 856-707-9700
  • Fax: 856-307-0289
Mailing address:
  • Phone: 856-707-9700
  • Fax: 856-307-0289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number40QA01407800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: