Healthcare Provider Details

I. General information

NPI: 1275362089
Provider Name (Legal Business Name): MARIAH JACKLYN GALLEGOS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2024
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13139 CENTRAL AVE NE
ALBUQUERQUE NM
87123-3031
US

IV. Provider business mailing address

13139 CENTRAL AVE NE
ALBUQUERQUE NM
87123-3031
US

V. Phone/Fax

Practice location:
  • Phone: 505-595-1607
  • Fax: 505-212-4610
Mailing address:
  • Phone: 505-595-1607
  • Fax: 505-212-4610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCTB-2026-0198
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: