Provider Demographics
NPI:1992967749
Name:GALLIEN GORMAN, JEANNE (OTR L)
Entity type:Individual
Prefix:
First Name:JEANNE
Middle Name:
Last Name:GALLIEN GORMAN
Suffix:
Gender:F
Credentials:OTR L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2208 N YELLOWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-9102
Mailing Address - Country:US
Mailing Address - Phone:918-286-1261
Mailing Address - Fax:
Practice Address - Street 1:2208 N YELLOWOOD AVE
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-9102
Practice Address - Country:US
Practice Address - Phone:918-286-1261
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-01
Last Update Date:2010-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1581225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist