Provider Demographics
NPI:1902082241
Name:GALLAGHER, MARTHA J (LOTR)
Entity type:Individual
Prefix:MS
First Name:MARTHA
Middle Name:J
Last Name:GALLAGHER
Suffix:
Gender:F
Credentials:LOTR
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 1331
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71273-1331
Mailing Address - Country:US
Mailing Address - Phone:318-255-9105
Mailing Address - Fax:
Practice Address - Street 1:1201 ATKINS RD
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-8717
Practice Address - Country:US
Practice Address - Phone:318-255-9105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-16
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAOTT.Z10170225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1300454Medicaid