Provider Demographics
NPI:1376077461
Name:GALLEGOS, MALIA MICHIKO (MA)
Entity Type:Individual
Prefix:
First Name:MALIA
Middle Name:MICHIKO
Last Name:GALLEGOS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:MALIA
Other - Middle Name:MICHIKO
Other - Last Name:OLIVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 70193
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91117-7193
Mailing Address - Country:US
Mailing Address - Phone:808-429-2923
Mailing Address - Fax:
Practice Address - Street 1:850 COLORADO BLVD
Practice Address - Street 2:STE 203
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90041-1738
Practice Address - Country:US
Practice Address - Phone:213-293-9923
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-14
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA90670106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA81-1268701OtherEMPLOYER IDENTIFICATION NUMBER