Basic Information
| Provider Information | |||||||||
| NPI: | 1265907984 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GALLOWAY | ||||||||
| FirstName: | CARLIE | ||||||||
| MiddleName: | DAYLE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 932 ORIZABA AVE | ||||||||
| Address2: | |||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908044929 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3183322211 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11420 WARNER AVE | ||||||||
| Address2: | |||||||||
| City: | FOUNTAIN VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927082529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145491300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2018 | ||||||||
| LastUpdateDate: | 10/09/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 9390 | LA | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 64234 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.