Provider Demographics
NPI:1134635287
Name:GALLEGOS, KATRINA J
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:J
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 1:908 COMER DR
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-3463
Mailing Address - Country:US
Mailing Address - Phone:505-400-8611
Mailing Address - Fax:
Practice Address - Street 1:908 COMER DR
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-3463
Practice Address - Country:US
Practice Address - Phone:505-400-8611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-26
Last Update Date:2017-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician