=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376634345
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RICHARD BALLOU GALLAHER JR. PHD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/27/2006
-----------------------------------------------------
Last Update Date | 01/08/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 513 THAIN ROAD
-----------------------------------------------------
City | LEWISTON
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83501-4140
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-743-0150
-----------------------------------------------------
Fax | 208-743-5358
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 513 THAIN ROAD
-----------------------------------------------------
City | LEWISTON
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83501-4140
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-743-0150
-----------------------------------------------------
Fax | 208-743-5358
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | PSY-202154
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | PY00000815
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------