Healthcare Provider Details

I. General information

NPI: 1275664559
Provider Name (Legal Business Name): JENNIFER LEE GALLO PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 S MAIN ST
POLAND OH
44514-1914
US

IV. Provider business mailing address

30 S MAIN ST
POLAND OH
44514-1914
US

V. Phone/Fax

Practice location:
  • Phone: 330-757-9772
  • Fax: 330-757-7296
Mailing address:
  • Phone: 330-757-9772
  • Fax: 330-757-7296

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number10394
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: