Basic Information
| Provider Information | |||||||||
| NPI: | 1134400369 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GALLAGHER | ||||||||
| FirstName: | JON | ||||||||
| MiddleName: | D. | ||||||||
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| Credential: | LADC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19 MAPLE ST | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | ME | ||||||||
| PostalCode: | 043304705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2074587780 | ||||||||
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| Practice Location | |||||||||
| Address1: | 67 EUSTIS PKWY | ||||||||
| Address2: | |||||||||
| City: | WATERVILLE | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049015173 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078732136 | ||||||||
| FaxNumber: | 2078724522 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2011 | ||||||||
| LastUpdateDate: | 09/01/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | LC4988 | ME | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.