Provider Demographics
NPI:1871264747
Name:GALLAGHER, ELOINA SANDOVAL (LASAC)
Entity Type:Individual
Prefix:
First Name:ELOINA
Middle Name:SANDOVAL
Last Name:GALLAGHER
Suffix:
Gender:F
Credentials:LASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7415 W BOSTON ST
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85226-3221
Mailing Address - Country:US
Mailing Address - Phone:480-547-1989
Mailing Address - Fax:
Practice Address - Street 1:7415 W BOSTON ST
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85226-3221
Practice Address - Country:US
Practice Address - Phone:480-547-1989
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-21
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLASAC-13318101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ072063Medicaid