Provider Demographics
NPI:1194925362
Name:GALLUP, TED ANDREW (PT)
Entity type:Individual
Prefix:
First Name:TED
Middle Name:ANDREW
Last Name:GALLUP
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11563 TEMPLAR DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-7547
Mailing Address - Country:US
Mailing Address - Phone:314-308-3071
Mailing Address - Fax:
Practice Address - Street 1:11563 TEMPLAR DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-7547
Practice Address - Country:US
Practice Address - Phone:314-308-3071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-24
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO02232225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist