Provider Demographics
NPI:1174562805
Name:GALLAGHER, ANDREW JR (PT)
Entity type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:
Last Name:GALLAGHER
Suffix:JR
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86 DUNROBIN LN
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06795-1712
Mailing Address - Country:US
Mailing Address - Phone:860-712-3080
Mailing Address - Fax:
Practice Address - Street 1:115 SPENCER ST
Practice Address - Street 2:SUITE 103
Practice Address - City:WINSTED
Practice Address - State:CT
Practice Address - Zip Code:06098-1140
Practice Address - Country:US
Practice Address - Phone:860-738-5810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2013-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT005572225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004208460Medicaid
CT076572Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER