Healthcare Provider Details

I. General information

NPI: 1326331661
Provider Name (Legal Business Name): DJ GALLEGOS LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2011
Last Update Date: 05/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2669 SCENIC DR 2539 MEDICAL DRIVE SUITE 106
ALAMOGORDO NM
88310-8700
US

IV. Provider business mailing address

2669 SCENIC DR 2539 MEDICAL DRIVE SUITE 106
ALAMOGORDO NM
88310-8700
US

V. Phone/Fax

Practice location:
  • Phone: 575-446-5300
  • Fax: 575-446-5304
Mailing address:
  • Phone: 575-446-5300
  • Fax: 575-446-5304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberI-1561
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: