Healthcare Provider Details

I. General information

NPI: 1285415653
Provider Name (Legal Business Name): NICOLE MARY GALLEGOS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2023
Last Update Date: 03/26/2026
Certification Date: 03/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

78150 CALLE TAMPICO STE 214
LA QUINTA CA
92253-2907
US

IV. Provider business mailing address

PO BOX 2723
INDIO CA
92202-2723
US

V. Phone/Fax

Practice location:
  • Phone: 760-423-3002
  • Fax:
Mailing address:
  • Phone: 760-423-3002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number137756
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: