Provider Demographics
NPI:1518572312
Name:GALLEGOS, MELLISSA M
Entity Type:Individual
Prefix:
First Name:MELLISSA
Middle Name:M
Last Name:GALLEGOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MELLISSA
Other - Middle Name:M
Other - Last Name:STOREY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2643 10TH CT SE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98501-2057
Mailing Address - Country:US
Mailing Address - Phone:509-850-6308
Mailing Address - Fax:
Practice Address - Street 1:2424 HERITAGE CT SW STE 200
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-6046
Practice Address - Country:US
Practice Address - Phone:360-810-1547
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-09
Last Update Date:2022-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician