Basic Information
| Provider Information | |||||||||
| NPI: | 1740240456 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GALLEGOS | ||||||||
| FirstName: | BETH | ||||||||
| MiddleName: | MI | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HODDE | ||||||||
| OtherFirstName: | BETH | ||||||||
| OtherMiddleName: | MI | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1404 BROAD STREET | ||||||||
| Address2: | |||||||||
| City: | GRINNELL | ||||||||
| State: | IA | ||||||||
| PostalCode: | 50112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6417810770 | ||||||||
| FaxNumber: | 6267957080 | ||||||||
| Practice Location | |||||||||
| Address1: | 807 4TH | ||||||||
| Address2: | |||||||||
| City: | GRINNELL | ||||||||
| State: | IA | ||||||||
| PostalCode: | 50112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6417810770 | ||||||||
| FaxNumber: | 6267957080 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2006 | ||||||||
| LastUpdateDate: | 07/03/2018 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LCS18431 | CA | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 18431 | CA | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 008368 | IA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.