Provider Demographics
NPI:1437806817
Name:GALLARDO, DIANA EVELYN
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:EVELYN
Last Name:GALLARDO
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 1:420 N OAKWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:WAUKEGAN
Mailing Address - State:IL
Mailing Address - Zip Code:60085-3015
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1122 BOB OFARRELL LN
Practice Address - Street 2:
Practice Address - City:BEACH PARK
Practice Address - State:IL
Practice Address - Zip Code:60099-4512
Practice Address - Country:US
Practice Address - Phone:224-595-7454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-07
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.105877104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker