Provider Demographics
NPI:1104283951
Name:GALLAGHER, MATTHEW (OT)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:GALLAGHER
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1091 PARK DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-2014
Mailing Address - Country:US
Mailing Address - Phone:770-207-6390
Mailing Address - Fax:678-374-4855
Practice Address - Street 1:1091 PARK DR
Practice Address - Street 2:SUITE B
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-2014
Practice Address - Country:US
Practice Address - Phone:770-207-6390
Practice Address - Fax:678-374-4855
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-25
Last Update Date:2016-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT006368225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist