MEDICARE: MOLLY GALLEGOS MA, OTR/L

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	225X00000X	Occupational Therapist	1574	ID

General Provider Information

NPI Number	:	1467814913
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MOLLY GALLEGOS MA, OTR/L

Provider Business Mailing Address
First Line	:	1906 W FAIRVIEW AVE
Second Line	:
City	:	CALDWELL
State	:	ID
Zip	:	83605
Country	:	US
Telephone Number	:	208-385-3680
Fax Number	:	208-385-3681

Provider Business Practice Location Address
First Line	:	1906 FAIRVIEW AVE STE 330
Second Line	:
City	:	CALDWELL
State	:	ID
Zip	:	83605-5425
Country	:	US
Telephone Number	:	208-385-3680
Fax Number	:	208-385-3681

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

Provider Enumeration Date	:	03/23/2016
Last Update Date	:	06/25/2019

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