Healthcare Provider Details

I. General information

NPI: 1225389182
Provider Name (Legal Business Name): SUSAN MARIE GALLARDO LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2012
Last Update Date: 07/08/2024
Certification Date: 06/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2016 SAN JACINTO ROAD
CAMP PENDLETON CA
92055
US

IV. Provider business mailing address

2016 SAN JACINTO ROAD
CAMP PENDLETON CA
92055
US

V. Phone/Fax

Practice location:
  • Phone: 760-719-4203
  • Fax:
Mailing address:
  • Phone: 760-719-4203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number18457
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS18457
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS 18457
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: