Healthcare Provider Details

I. General information

NPI: 1376413385
Provider Name (Legal Business Name): KIM GALLO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2025
Last Update Date: 11/06/2025
Certification Date: 11/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21331 SANDIA RD
APPLE VALLEY CA
92308-7722
US

IV. Provider business mailing address

12555 NAVAJO RD
APPLE VALLEY CA
92308-7256
US

V. Phone/Fax

Practice location:
  • Phone: 760-240-5125
  • Fax:
Mailing address:
  • Phone: 760-247-8001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number230093367
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: