1649379033 NPI number — WENDY JOAN GALLEGOS M.A. CCC-A

Table of content: WENDY JOAN GALLEGOS M.A. CCC-A (NPI 1649379033)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649379033 NPI number — WENDY JOAN GALLEGOS M.A. CCC-A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GALLEGOS
Provider First Name:
WENDY
Provider Middle Name:
JOAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.A. CCC-A
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649379033
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/24/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
420 ASHLEY LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORRALES
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87048-8940
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-898-2474
Provider Business Mailing Address Fax Number:
505-899-8172

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3949 CORRALES RD
Provider Second Line Business Practice Location Address:
STE 210
Provider Business Practice Location Address City Name:
CORRALES
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87048-9347
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-898-2474
Provider Business Practice Location Address Fax Number:
505-899-8172
Provider Enumeration Date:
09/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 231H00000X , with the licence number:  NM562 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 231H00000X , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: K2186 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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