Basic Information
| Provider Information | |||||||||
| NPI: | 1235282799 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GALLOGLY | ||||||||
| FirstName: | TALLY | ||||||||
| MiddleName: | WILLIAM | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LPCC, LICDC, SAP,CEA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 715 S TAFT AVE | ||||||||
| Address2: | |||||||||
| City: | FREMONT | ||||||||
| State: | OH | ||||||||
| PostalCode: | 434203200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193346669 | ||||||||
| FaxNumber: | 4193346671 | ||||||||
| Practice Location | |||||||||
| Address1: | 715 S TAFT AVE | ||||||||
| Address2: | |||||||||
| City: | FREMONT | ||||||||
| State: | OH | ||||||||
| PostalCode: | 434203200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193346669 | ||||||||
| FaxNumber: | 4193346671 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 101YM0800X | E0003436 | OH | X | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | X | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.