Provider Demographics
NPI:1205390879
Name:GALLEGO, ORVILLE
Entity Type:Individual
Prefix:
First Name:ORVILLE
Middle Name:
Last Name:GALLEGO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8605 VANALDEN AVE
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91324-4365
Mailing Address - Country:US
Mailing Address - Phone:818-235-3771
Mailing Address - Fax:
Practice Address - Street 1:19401 S VERMONT AVE STE A200
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90502-4418
Practice Address - Country:US
Practice Address - Phone:310-323-6887
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-28
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAOT21498225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program