Healthcare Provider Details

I. General information

NPI: 1780132076
Provider Name (Legal Business Name): MR. IGNACIO GALLEGOS JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2016
Last Update Date: 09/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

914 MISSION AVE 3RD FLOOR
SAN RAFAEL CA
94901-6106
US

IV. Provider business mailing address

243 CARINA DR
SANTA ROSA CA
95401-5815
US

V. Phone/Fax

Practice location:
  • Phone: 415-457-6964
  • Fax:
Mailing address:
  • Phone: 707-217-3961
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: