Provider Demographics
NPI:1649379033
Name:GALLEGOS, WENDY JOAN (MA CCC-A)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:JOAN
Last Name:GALLEGOS
Suffix:
Gender:F
Credentials:MA CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 ASHLEY LN
Mailing Address - Street 2:
Mailing Address - City:CORRALES
Mailing Address - State:NM
Mailing Address - Zip Code:87048-8940
Mailing Address - Country:US
Mailing Address - Phone:505-898-2474
Mailing Address - Fax:505-899-8172
Practice Address - Street 1:3949 CORRALES RD
Practice Address - Street 2:STE 210
Practice Address - City:CORRALES
Practice Address - State:NM
Practice Address - Zip Code:87048-9347
Practice Address - Country:US
Practice Address - Phone:505-898-2474
Practice Address - Fax:505-899-8172
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMNM562231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM231H00000XMedicaid
NMK2186Medicaid
NMK2186Medicaid
NMS84174Medicare UPIN