Healthcare Provider Details

I. General information

NPI: 1538676176
Provider Name (Legal Business Name): ANDREW GALLEGOS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2018
Last Update Date: 01/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5201 VENICE AVE NE STE A
ALBUQUERQUE NM
87113-2337
US

IV. Provider business mailing address

2821 PALOMAS DR NE
ALBUQUERQUE NM
87110-3121
US

V. Phone/Fax

Practice location:
  • Phone: 505-916-2007
  • Fax:
Mailing address:
  • Phone: 505-450-7323
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberT-CTL0193831
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: