MEDICARE: ELIZABETH 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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1841620747
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZABETH GALLEGOS

Provider Business Mailing Address
First Line	:	9344 SE SCHILLER ST APT D
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97266
Country	:	US
Telephone Number	:	503-726-3740
Fax Number	:

Provider Business Practice Location Address
First Line	:	9344 SE SCHILLER ST APT D
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97266-2751
Country	:	US
Telephone Number	:	503-726-3740
Fax Number	:

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

Provider Enumeration Date	:	11/14/2013
Last Update Date	:	11/14/2013

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