Healthcare Provider Details

I. General information

NPI: 1033342597
Provider Name (Legal Business Name): TRACEY GALLEGOS CCC-SLP/A
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2009
Last Update Date: 12/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 ASHLEY LN
CORRALES NM
87048-8940
US

IV. Provider business mailing address

194 CALLE VISTA GRANDE
BERNALILLO NM
87004-6066
US

V. Phone/Fax

Practice location:
  • Phone: 505-898-2474
  • Fax:
Mailing address:
  • Phone: 505-918-0700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberC-4603
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number6126
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: