Provider Demographics
NPI:1174173082
Name:GALLAGHER, JANICE LOAN (MS, AT-C, AT-L, CSCS)
Entity type:Individual
Prefix:
First Name:JANICE
Middle Name:LOAN
Last Name:GALLAGHER
Suffix:
Gender:F
Credentials:MS, AT-C, AT-L, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 N RIVER RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT CLEMENS
Mailing Address - State:MI
Mailing Address - Zip Code:48043-1903
Mailing Address - Country:US
Mailing Address - Phone:586-465-1872
Mailing Address - Fax:
Practice Address - Street 1:10 N RIVER RD
Practice Address - Street 2:
Practice Address - City:MOUNT CLEMENS
Practice Address - State:MI
Practice Address - Zip Code:48043-1903
Practice Address - Country:US
Practice Address - Phone:586-465-1872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-13
Last Update Date:2019-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010002762255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer