Basic Information
Provider Information | |||||||||
NPI: | 1831644319 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GALLEGOS | ||||||||
FirstName: | KOURTNEY | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | VAN ZANT | ||||||||
OtherFirstName: | KOURTNEY | ||||||||
OtherMiddleName: | MARIE | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 645 S ROGERS ST | ||||||||
Address2: |   | ||||||||
City: | BLOOMINGTON | ||||||||
State: | IN | ||||||||
PostalCode: | 474032353 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8123391691 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 421 S WALNUT ST STE 200 | ||||||||
Address2: |   | ||||||||
City: | MUNCIE | ||||||||
State: | IN | ||||||||
PostalCode: | 473052484 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7652881790 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/24/2016 | ||||||||
LastUpdateDate: | 02/10/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/10/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X |   |   | N |   | Behavioral Health & Social Service Providers | Social Worker |   | 1041C0700X | 34008725A | IN | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.