=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093160947
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARY ANNE GALLAGHER, PH.D.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/28/2016
-----------------------------------------------------
Last Update Date | 04/28/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2550 HONOLULU AVE STE 103
-----------------------------------------------------
City | MONTROSE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91020-1859
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-243-5674
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2550 HONOLULU AVE STE 103
-----------------------------------------------------
City | MONTROSE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91020-1859
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-243-5674
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MARY ANNE GALLAGHER
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 818-243-5674
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | MFT34415
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------