MEDICARE: MALIA MICHIKO GALLEGOS M.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	90670	CA

General Provider Information

NPI Number	:	1376077461
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MALIA MICHIKO GALLEGOS M.A.

Provider Business Mailing Address
First Line	:	PO BOX 70193
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91117-7193
Country	:	US
Telephone Number	:	808-429-2923
Fax Number	:

Provider Business Practice Location Address
First Line	:	850 COLORADO BLVD
Second Line	:	STE 203
City	:	LOS ANGELES
State	:	CA
Zip	:	90041-1738
Country	:	US
Telephone Number	:	213-293-9923
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/14/2017
Last Update Date	:	04/21/2017

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