Provider Demographics
NPI:1326331661
Name:GALLEGOS, DJ (LISW)
Entity Type:Individual
Prefix:MRS
First Name:DJ
Middle Name:
Last Name:GALLEGOS
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2669 SCENIC DR
Mailing Address - Street 2:2539 MEDICAL DRIVE SUITE 106
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-8700
Mailing Address - Country:US
Mailing Address - Phone:575-446-5300
Mailing Address - Fax:575-446-5304
Practice Address - Street 1:2669 SCENIC DR
Practice Address - Street 2:2539 MEDICAL DRIVE SUITE 106
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-8700
Practice Address - Country:US
Practice Address - Phone:575-446-5300
Practice Address - Fax:575-446-5304
Is Sole Proprietor?:No
Enumeration Date:2011-05-19
Last Update Date:2011-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-1561103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMI1561OtherLISW