Provider Demographics
NPI:1104931708
Name:GALLAGHER, JOHN PATRICK II (PH D)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:PATRICK
Last Name:GALLAGHER
Suffix:II
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5524 S EMERSON AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46237-2517
Mailing Address - Country:US
Mailing Address - Phone:317-781-1917
Mailing Address - Fax:317-781-8170
Practice Address - Street 1:5524 S EMERSON AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-2517
Practice Address - Country:US
Practice Address - Phone:317-781-1917
Practice Address - Fax:317-781-8170
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040155A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN10067770Medicaid
INGA522170Medicare ID - Type Unspecified