Provider Demographics
NPI:1003117821
Name:GALLEGOS, GUILLERMO ENRIQUE (PH D)
Entity Type:Individual
Prefix:DR
First Name:GUILLERMO
Middle Name:ENRIQUE
Last Name:GALLEGOS
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:336 MOUNTAIN WAY
Mailing Address - Street 2:
Mailing Address - City:RUTHERFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07070-2817
Mailing Address - Country:US
Mailing Address - Phone:908-239-2338
Mailing Address - Fax:201-933-1326
Practice Address - Street 1:5 FIR CT STE 2
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:NJ
Practice Address - Zip Code:07436-1821
Practice Address - Country:US
Practice Address - Phone:908-239-2338
Practice Address - Fax:201-933-1326
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-10
Last Update Date:2010-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJSIOO2556103TC0700X
NY16943103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJGA636660Medicare PIN