Provider Demographics
NPI:1548561152
Name:GALLEGOS, MARY AUDRIENE (SSW)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:AUDRIENE
Last Name:GALLEGOS
Suffix:
Gender:F
Credentials:SSW
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:AUDRIENE
Other - Last Name:FULLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:663 W 950 S
Mailing Address - Street 2:
Mailing Address - City:BRIGHAM CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84302-3021
Mailing Address - Country:US
Mailing Address - Phone:435-734-9449
Mailing Address - Fax:435-723-4851
Practice Address - Street 1:663 W 950 S
Practice Address - Street 2:
Practice Address - City:BRIGHAM CITY
Practice Address - State:UT
Practice Address - Zip Code:84302-3021
Practice Address - Country:US
Practice Address - Phone:435-734-9449
Practice Address - Fax:435-723-4851
Is Sole Proprietor?:No
Enumeration Date:2010-11-12
Last Update Date:2010-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7544766-3503104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker