MEDICARE: GABRIELA MAGALLANES LCAS-A

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	LCAS-28970	NC
2	1041C0700X	Clinical Social Worker	P019583	NC

General Provider Information

NPI Number	:	1932887494
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GABRIELA MAGALLANES LCAS-A

Provider Business Mailing Address
First Line	:	612 GARDNER ST
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27607-6940
Country	:	US
Telephone Number	:	919-623-6433
Fax Number	:

Provider Business Practice Location Address
First Line	:	8045 ARCO CORPORATE DR STE 120
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27617-8134
Country	:	US
Telephone Number	:	919-372-3690
Fax Number	:

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

Provider Enumeration Date	:	07/06/2023
Last Update Date	:	05/23/2024

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