Provider Demographics
NPI:1821213091
Name:GALLARDO, MIGUEL (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MIGUEL
Middle Name:
Last Name:GALLARDO
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 BLUEBIRD LN
Mailing Address - Street 2:
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-1762
Mailing Address - Country:US
Mailing Address - Phone:949-215-2960
Mailing Address - Fax:
Practice Address - Street 1:18111 VON KARMAN AVE
Practice Address - Street 2:SUITE 209
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92612-0199
Practice Address - Country:US
Practice Address - Phone:949-223-2524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY.D 21360103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY.D 21360OtherCALIF LIC