Provider Demographics
NPI:1063904266
Name:GALLAGHER, LOUISE KNETZGER (LAC)
Entity type:Individual
Prefix:
First Name:LOUISE
Middle Name:KNETZGER
Last Name:GALLAGHER
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:LOUISE
Other - Middle Name:W
Other - Last Name:KNETZGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 683000
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84068-3000
Mailing Address - Country:US
Mailing Address - Phone:435-901-4212
Mailing Address - Fax:
Practice Address - Street 1:1107 WOODSIDE AVE
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84060
Practice Address - Country:US
Practice Address - Phone:435-901-4212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-04
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9444443-1201171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist