Healthcare Provider Details

I. General information

NPI: 1366372609
Provider Name (Legal Business Name): NIKKI CHANTELLE GALLARDO LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: NIKKI CHANTELLE NYSTROM

II. Dates (important events)

Enumeration Date: 05/20/2026
Last Update Date: 05/20/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2402 PIONEER AVE
CHEYENNE WY
82001-3021
US

IV. Provider business mailing address

1950 GET LUCKY TRL APT B
CHEYENNE WY
82007
US

V. Phone/Fax

Practice location:
  • Phone: 307-757-5907
  • Fax:
Mailing address:
  • Phone: 785-789-2239
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW.09932589
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-1887
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: