Provider Demographics
NPI:1821701848
Name:GALLEGOS, RICKY RICARDO JR (RADT)
Entity Type:Individual
Prefix:MR
First Name:RICKY
Middle Name:RICARDO
Last Name:GALLEGOS
Suffix:JR
Gender:M
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1876 ARCH ST APT 4A
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94709-1306
Mailing Address - Country:US
Mailing Address - Phone:510-258-7121
Mailing Address - Fax:
Practice Address - Street 1:1816 SCENIC AVE
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94709-1324
Practice Address - Country:US
Practice Address - Phone:510-548-7270
Practice Address - Fax:510-843-7331
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-04
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)