Provider Demographics
NPI:1316309495
Name:GALLUP, ADA (PLPC)
Entity type:Individual
Prefix:
First Name:ADA
Middle Name:
Last Name:GALLUP
Suffix:
Gender:F
Credentials:PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 VANDIVER DR
Mailing Address - Street 2:BUILDING 4, SUITE 102
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65202-3754
Mailing Address - Country:US
Mailing Address - Phone:573-239-6642
Mailing Address - Fax:
Practice Address - Street 1:409 VANDIVER DR STE 102
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65202-3754
Practice Address - Country:US
Practice Address - Phone:573-239-6642
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-28
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016008293101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional