Provider Demographics
NPI:1588769699
Name:GALLAGHER, KEVIN P (MS, LCMHC)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:P
Last Name:GALLAGHER
Suffix:
Gender:M
Credentials:MS, LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 NORTHSHORE DR
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-1250
Mailing Address - Country:US
Mailing Address - Phone:802-651-7674
Mailing Address - Fax:802-658-1777
Practice Address - Street 1:2 CHURCH ST
Practice Address - Street 2:SUITE 4G
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-4299
Practice Address - Country:US
Practice Address - Phone:802-651-7674
Practice Address - Fax:802-658-1777
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1005799Medicaid