=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750096590
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DEBRA SUE GALLENBERG LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/17/2023
-----------------------------------------------------
Last Update Date | 01/17/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | N11228 ANTIGO STREET
-----------------------------------------------------
City | ELCHO
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54428
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-610-7835
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | W10250 COUNTY ROAD K
-----------------------------------------------------
City | ELCHO
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54428-9719
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-275-3228
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 15739-146
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------