Provider Demographics
NPI:1053074526
Name:GALLEGOS, ALEXIS JUSTINE
Entity Type:Individual
Prefix:MRS
First Name:ALEXIS
Middle Name:JUSTINE
Last Name:GALLEGOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1608 BLACKHAWK RIVER DR NE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87144-6416
Mailing Address - Country:US
Mailing Address - Phone:505-670-3155
Mailing Address - Fax:
Practice Address - Street 1:1608 BLACKHAWK RIVER DR NE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87144-6416
Practice Address - Country:US
Practice Address - Phone:505-670-3155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-20
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician