Provider Demographics
NPI:1376799635
Name:GALLEGOS, LORRAINE MADRID (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LORRAINE
Middle Name:MADRID
Last Name:GALLEGOS
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:LORRIE
Other - Middle Name:MADRID
Other - Last Name:GALLEGOS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:10640 N 28TH DR STE C104
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85029-2937
Mailing Address - Country:US
Mailing Address - Phone:602-626-8851
Mailing Address - Fax:602-865-8020
Practice Address - Street 1:10640 N 28TH DR STE C104
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85029-2937
Practice Address - Country:US
Practice Address - Phone:602-626-8851
Practice Address - Fax:602-865-8020
Is Sole Proprietor?:No
Enumeration Date:2008-08-18
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP1630235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist