MEDICARE: CHANELLE GALLAGHER MSW, LICSW

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	1041C0700X	Clinical Social Worker	25407	MN

General Provider Information

NPI Number	:	1437781234
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHANELLE GALLAGHER MSW, LICSW

Provider Business Mailing Address
First Line	:	1508 E FRANKLIN AVE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55404-2157
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2012 CEDAR AVE S
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55404-3101
Country	:	US
Telephone Number	:	612-813-1610
Fax Number	:

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

Provider Enumeration Date	:	02/10/2020
Last Update Date	:	07/08/2021

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