Provider Demographics
NPI:1235602962
Name:GALLEGO, GENNESIS ANDREA
Entity Type:Individual
Prefix:
First Name:GENNESIS
Middle Name:ANDREA
Last Name:GALLEGO
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 1:1601 METROPOLITAN AVE APT 2A
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10462-6244
Mailing Address - Country:US
Mailing Address - Phone:646-546-7679
Mailing Address - Fax:
Practice Address - Street 1:1 RIVERDALE AVE STE 3
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10463-4903
Practice Address - Country:US
Practice Address - Phone:929-447-5262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-04
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency