Provider Demographics
NPI:1366157851
Name:GALLAGHER, ELIZA (MED)
Entity type:Individual
Prefix:
First Name:ELIZA
Middle Name:
Last Name:GALLAGHER
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5714 4TH ST N
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22205-1004
Mailing Address - Country:US
Mailing Address - Phone:804-332-0256
Mailing Address - Fax:
Practice Address - Street 1:8227 OLD COURTHOUSE RD STE 215
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22182-3815
Practice Address - Country:US
Practice Address - Phone:703-783-4315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-18
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0704007238101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health