MEDICARE: JACQUELINE HELEN GALLAGHER OTD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225XP0200X	Pediatric Occupational Therapist	17779	NC
2	225XP0200X	Pediatric Occupational Therapist	008636	AZ

General Provider Information

NPI Number	:	1417619099
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE HELEN GALLAGHER OTD

Provider Business Mailing Address
First Line	:	8420 UNIVERSITY EXEC PARK DR STE 825
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28262-1346
Country	:	US
Telephone Number	:	704-727-4830
Fax Number	:

Provider Business Practice Location Address
First Line	:	8420 UNIVERSITY EXEC PARK DR STE 825
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28262-1346
Country	:	US
Telephone Number	:	704-727-4830
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/11/2021
Last Update Date	:	01/27/2026

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