Provider Demographics
NPI:1487425278
Name:GALLOIS, RICHARD LAURENT III
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:LAURENT
Last Name:GALLOIS
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2332 W MCMICKEN AVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45214-1817
Mailing Address - Country:US
Mailing Address - Phone:513-633-1040
Mailing Address - Fax:
Practice Address - Street 1:7058 CORPORATE WAY STE 3
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45459-4243
Practice Address - Country:US
Practice Address - Phone:513-377-9374
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-11
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.186384101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty