Provider Demographics
NPI:1043917776
Name:GALLARDO, MARTIN (RADT)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:
Last Name:GALLARDO
Suffix:
Gender:M
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1003 S BEACON ST
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-4324
Mailing Address - Country:US
Mailing Address - Phone:310-514-4940
Mailing Address - Fax:
Practice Address - Street 1:1003 S BEACON ST
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-4324
Practice Address - Country:US
Practice Address - Phone:310-514-4940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-13
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1495280123101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)