1639356793 NPI number — MRS. SUSAN KAYE GALLOWAY LPC

Table of content: MRS. SUSAN KAYE GALLOWAY LPC (NPI 1639356793)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639356793 NPI number — MRS. SUSAN KAYE GALLOWAY LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GALLOWAY
Provider First Name:
SUSAN
Provider Middle Name:
KAYE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BORRESON
Provider Other First Name:
SUSAN
Provider Other Middle Name:
KAY
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1639356793
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/13/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1191 BROWNSMILL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELSBERRY
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63343
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
636-697-2747
Provider Business Mailing Address Fax Number:
573-898-2168

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
104 MOUND
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TROY
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63379
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
636-697-2747
Provider Business Practice Location Address Fax Number:
573-898-2168
Provider Enumeration Date:
01/30/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X , with the licence number:  2007031028 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1639356793 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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