Provider Demographics
NPI:1558911305
Name:GALLEGOS, GREGORY (RADT-I)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:
Last Name:GALLEGOS
Suffix:
Gender:M
Credentials:RADT-I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7466 GUTHRIE ST APT B
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92410-4376
Mailing Address - Country:US
Mailing Address - Phone:323-921-5877
Mailing Address - Fax:
Practice Address - Street 1:3316 W BEVERLY BLVD
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-1537
Practice Address - Country:US
Practice Address - Phone:323-722-4529
Practice Address - Fax:323-722-4450
Is Sole Proprietor?:No
Enumeration Date:2019-09-13
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1361770819101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)