=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063661353
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT P GALLIGAN PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2008
-----------------------------------------------------
Last Update Date | 11/16/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 779 CARROLL ST 1ST FLOOR
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11215-1402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-693-4759
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 74 4TH PL GROUND FLOOR
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11231-4008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-693-4759
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 019380
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC2200X
-----------------------------------------------------
Taxonomy Name | Clinical Child & Adolescent Psychologist
-----------------------------------------------------
License Number | 019380
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------