Provider Demographics
NPI:1124212477
Name:GALLEGOS, AGUSTINA P (MFT)
Entity Type:Individual
Prefix:MS
First Name:AGUSTINA
Middle Name:P
Last Name:GALLEGOS
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:AGUSTINA
Other - Middle Name:
Other - Last Name:POLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:788 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:HOLLISTER
Mailing Address - State:CA
Mailing Address - Zip Code:95023-4105
Mailing Address - Country:US
Mailing Address - Phone:831-297-3811
Mailing Address - Fax:
Practice Address - Street 1:449 SAN BENITO ST STE 26
Practice Address - Street 2:
Practice Address - City:HOLLISTER
Practice Address - State:CA
Practice Address - Zip Code:95023-3962
Practice Address - Country:US
Practice Address - Phone:831-524-3878
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-30
Last Update Date:2007-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 44550106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist