Provider Demographics
NPI:1649743188
Name:GALLARDO, CRISTINA MARIA (LCDA)
Entity Type:Individual
Prefix:
First Name:CRISTINA
Middle Name:MARIA
Last Name:GALLARDO
Suffix:
Gender:F
Credentials:LCDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 561235
Mailing Address - Street 2:
Mailing Address - City:GUAYANILLA
Mailing Address - State:PR
Mailing Address - Zip Code:00656-3235
Mailing Address - Country:US
Mailing Address - Phone:787-447-4653
Mailing Address - Fax:
Practice Address - Street 1:PLAZA REAL ANON COTTO LAUREL CARRETERA 10
Practice Address - Street 2:
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00730
Practice Address - Country:US
Practice Address - Phone:787-447-4653
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-08
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR3758103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist