Provider Demographics
NPI:1164908729
Name:GALLARDO, RENE (LCSW, PPS)
Entity Type:Individual
Prefix:
First Name:RENE
Middle Name:
Last Name:GALLARDO
Suffix:
Gender:M
Credentials:LCSW, PPS
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 4094
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92863-4094
Mailing Address - Country:US
Mailing Address - Phone:909-684-1380
Mailing Address - Fax:
Practice Address - Street 1:265 S RANDOLPH AVE STE 290
Practice Address - Street 2:
Practice Address - City:BREA
Practice Address - State:CA
Practice Address - Zip Code:92821-5702
Practice Address - Country:US
Practice Address - Phone:714-924-4241
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-17
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA101YM0800XMedicaid