Provider Demographics
NPI:1912737842
Name:GALLOGLY, AUDRA JEAN (LCSW)
Entity type:Individual
Prefix:
First Name:AUDRA
Middle Name:JEAN
Last Name:GALLOGLY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1915 LARSON CT
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:CO
Mailing Address - Zip Code:80516-7578
Mailing Address - Country:US
Mailing Address - Phone:303-669-4132
Mailing Address - Fax:
Practice Address - Street 1:1120 W SOUTH BOULDER RD STE 101B
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CO
Practice Address - Zip Code:80026-8952
Practice Address - Country:US
Practice Address - Phone:303-389-2793
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-05
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO009921631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical