Provider Demographics
NPI:1124253760
Name:GALLANT THERAPY SERVICES
Entity type:Organization
Organization Name:GALLANT THERAPY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GALLANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-623-3900
Mailing Address - Street 1:12 SPRUCE ST.
Mailing Address - Street 2:SUITE 3
Mailing Address - City:AUGUSTA
Mailing Address - State:ME
Mailing Address - Zip Code:04330-7886
Mailing Address - Country:US
Mailing Address - Phone:207-623-3900
Mailing Address - Fax:
Practice Address - Street 1:12 SHUMAN AVE STE 16
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330-6020
Practice Address - Country:US
Practice Address - Phone:207-623-3900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-27
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME172740000Medicaid
ME434551000Medicaid