=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386045193
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICHOLAS P GALLO PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2014
-----------------------------------------------------
Last Update Date | 09/11/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2675 EAST 30TH STREET NERC
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44115-4115
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-771-6460
-----------------------------------------------------
Fax | 216-623-0992
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2675 EAST 30TH ST
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44115-4115
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-771-6460
-----------------------------------------------------
Fax | 216-623-0992
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 1890
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------