Basic Information
| Provider Information | |||||||||
| NPI: | 1558604777 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GALLOWAY | ||||||||
| FirstName: | KATHLEEN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1505 WATERFORD PKWY | ||||||||
| Address2: | |||||||||
| City: | SAINT JOHNS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488799630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9892243000 | ||||||||
| FaxNumber: | 9892240951 | ||||||||
| Practice Location | |||||||||
| Address1: | 1505 WATERFORD PKWY | ||||||||
| Address2: | |||||||||
| City: | SAINT JOHNS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488799630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9892243000 | ||||||||
| FaxNumber: | 9892240951 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2013 | ||||||||
| LastUpdateDate: | 04/05/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 6301015458 | MI | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.