Basic Information
| Provider Information | |||||||||
| NPI: | 1881999134 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GALLEGOS | ||||||||
| FirstName: | CANDELARIA | ||||||||
| MiddleName: | ERNESTINA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 28220 | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875928220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5054715006 | ||||||||
| FaxNumber: | 5058209220 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 S 4TH ST | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA | ||||||||
| State: | NM | ||||||||
| PostalCode: | 884352417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5754720745 | ||||||||
| FaxNumber: | 5754720746 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2011 | ||||||||
| LastUpdateDate: | 01/18/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.