Provider Demographics
NPI:1275256083
Name:GALLEGOS, ANNIZA MICHELLE
Entity Type:Individual
Prefix:
First Name:ANNIZA
Middle Name:MICHELLE
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 1:455 BERLAND WAY
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-6422
Mailing Address - Country:US
Mailing Address - Phone:619-534-1673
Mailing Address - Fax:
Practice Address - Street 1:1733 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92105-5414
Practice Address - Country:US
Practice Address - Phone:619-263-0433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-26
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARADT101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool