Provider Demographics
NPI:1174916985
Name:GALLEGOS, RAFAEL S (CADCA)
Entity type:Individual
Prefix:
First Name:RAFAEL
Middle Name:S
Last Name:GALLEGOS
Suffix:
Gender:M
Credentials:CADCA
Other - Prefix:MR
Other - First Name:RAFAEL
Other - Middle Name:S
Other - Last Name:GALLEGOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CADCA
Mailing Address - Street 1:6231 NEWELL ST
Mailing Address - Street 2:APT C
Mailing Address - City:HUNTINGTON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90255-4555
Mailing Address - Country:US
Mailing Address - Phone:626-472-8254
Mailing Address - Fax:
Practice Address - Street 1:6231 NEWELL ST
Practice Address - Street 2:APT C
Practice Address - City:HUNTINGTON PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-4555
Practice Address - Country:US
Practice Address - Phone:626-472-8254
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-18
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAI3151011101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)