Healthcare Provider Details

I. General information

NPI: 1609992338
Provider Name (Legal Business Name): MRS. ELLEN ANN GALLAGHER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1104 WELSH RD
PHILADELPHIA PA
19115-3730
US

IV. Provider business mailing address

3337 DECATUR ST
PHILADELPHIA PA
19136-3021
US

V. Phone/Fax

Practice location:
  • Phone: 215-676-9191
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberTE001435L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: