Provider Demographics
NPI:1316064082
Name:GALLANT, DERRICK C (THERAPY DIR I)
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:C
Last Name:GALLANT
Suffix:
Gender:M
Credentials:THERAPY DIR I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3755
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68103-0755
Mailing Address - Country:US
Mailing Address - Phone:402-354-2100
Mailing Address - Fax:402-354-2155
Practice Address - Street 1:8005 FARNAM DR STE 303
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-3426
Practice Address - Country:US
Practice Address - Phone:402-354-9070
Practice Address - Fax:402-354-9075
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2015-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1516225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10026252200Medicaid
NE10026445500Medicaid
NE10025896000Medicaid
NE10026056700Medicaid
NE10025895900Medicaid
NE10025941700Medicaid
NE10025896100Medicaid
IA1316064082Medicaid
NE10026056700Medicaid
NE10026056700Medicaid
NE10025896000Medicaid
NE099668009Medicare PIN