Provider Demographics
NPI:1497206304
Name:GALLARDO, LIZETTE
Entity Type:Individual
Prefix:
First Name:LIZETTE
Middle Name:
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 1:9445 FARNHAM ST STE 100
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-1399
Mailing Address - Country:US
Mailing Address - Phone:858-380-4676
Mailing Address - Fax:
Practice Address - Street 1:730 MEDICAL CENTER CT
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-6618
Practice Address - Country:US
Practice Address - Phone:619-591-5740
Practice Address - Fax:619-591-5744
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-17
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor