MEDICARE: AMANDA GALLEGOS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor

General Provider Information

NPI Number	:	1184031643
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA GALLEGOS

Provider Business Mailing Address
First Line	:	8500 WASHINGTON ST NE
Second Line	:	SUITE A-1
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87113-1846
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8500 WASHINGTON ST NE
Second Line	:	SUITE A-1
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87113-1846
Country	:	US
Telephone Number	:	505-697-7611
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/16/2014
Last Update Date	:	06/03/2015

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