MEDICARE: JUAN SEBASTIAN GALLO

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	101YM0800X	Mental Health Counselor	20238	FL

General Provider Information

NPI Number	:	1750032470
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUAN SEBASTIAN GALLO

Provider Business Mailing Address
First Line	:	1422 SW 106TH WAY
Second Line	:
City	:	DAVIE
State	:	FL
Zip	:	33324-7102
Country	:	US
Telephone Number	:	954-612-2977
Fax Number	:

Provider Business Practice Location Address
First Line	:	2701 W CYPRESS CREEK RD
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33309-1703
Country	:	US
Telephone Number	:	954-612-2977
Fax Number	:

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

Provider Enumeration Date	:	01/13/2022
Last Update Date	:	01/13/2022

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