Provider Demographics
NPI:1689375511
Name:GALLEGOS, IVETH
Entity Type:Individual
Prefix:
First Name:IVETH
Middle Name:
Last Name:GALLEGOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 LIME ST
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92501-2971
Mailing Address - Country:US
Mailing Address - Phone:909-447-9394
Mailing Address - Fax:
Practice Address - Street 1:3600 LIME ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-2971
Practice Address - Country:US
Practice Address - Phone:909-447-9394
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-16
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician