Provider Demographics
NPI:1871562314
Name:GALLAGHER, MORIA MALAT (OTR)
Entity type:Individual
Prefix:MS
First Name:MORIA
Middle Name:MALAT
Last Name:GALLAGHER
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13024 EUROPA TRL N
Mailing Address - Street 2:
Mailing Address - City:HUGO
Mailing Address - State:MN
Mailing Address - Zip Code:55038-4410
Mailing Address - Country:US
Mailing Address - Phone:651-482-9126
Mailing Address - Fax:
Practice Address - Street 1:10721 SMETANA RD
Practice Address - Street 2:#220
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55343-8080
Practice Address - Country:US
Practice Address - Phone:952-936-9215
Practice Address - Fax:952-936-9942
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN100722235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN39G11GAOtherBLUE CROSS/BLUE SHIELD
MN64-01779OtherMEDICA
MNHP34800OtherHEALTHPARTNERS