Provider Demographics
NPI:1588403091
Name:GALLAGHER, ETHAN DANIEL
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:DANIEL
Last Name:GALLAGHER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 34990
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-0627
Mailing Address - Country:US
Mailing Address - Phone:610-359-5672
Mailing Address - Fax:
Practice Address - Street 1:119 E UWCHLAN AVE STE 201
Practice Address - Street 2:
Practice Address - City:EXTON
Practice Address - State:PA
Practice Address - Zip Code:19341-1293
Practice Address - Country:US
Practice Address - Phone:610-557-8182
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-23
Last Update Date:2025-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATPT0238302251P0200X
PAPT032515225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics