Provider Demographics
NPI:1114285889
Name:GALLEGOS-RANDEL, VICKY LYNN (LPC)
Entity Type:Individual
Prefix:
First Name:VICKY
Middle Name:LYNN
Last Name:GALLEGOS-RANDEL
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 966
Mailing Address - Street 2:
Mailing Address - City:NOME
Mailing Address - State:AK
Mailing Address - Zip Code:99762-0966
Mailing Address - Country:US
Mailing Address - Phone:907-443-3311
Mailing Address - Fax:907-443-5915
Practice Address - Street 1:607 DIVISION STREET
Practice Address - Street 2:
Practice Address - City:NOME
Practice Address - State:AK
Practice Address - Zip Code:99762
Practice Address - Country:US
Practice Address - Phone:907-443-3311
Practice Address - Fax:907-443-5915
Is Sole Proprietor?:No
Enumeration Date:2012-05-01
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK874101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1020986Medicaid