Provider Demographics
NPI:1568718682
Name:GALLOSO, BENJAMIN D (LCSW, CAP, AHCT)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:D
Last Name:GALLOSO
Suffix:
Gender:M
Credentials:LCSW, CAP, AHCT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:733 N.W. 30TH COURT
Mailing Address - Street 2:APT 7
Mailing Address - City:WILTON MANORS
Mailing Address - State:FL
Mailing Address - Zip Code:33311-1798
Mailing Address - Country:US
Mailing Address - Phone:786-216-9868
Mailing Address - Fax:
Practice Address - Street 1:2900 W PROSPECT RD
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33309-2519
Practice Address - Country:US
Practice Address - Phone:954-770-2363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-26
Last Update Date:2014-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCAP4290101YA0400X
FLSW83461041C0700X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health