Provider Demographics
NPI:1891981924
Name:GALLEGOS, PRUDENSO SAM
Entity Type:Individual
Prefix:
First Name:PRUDENSO
Middle Name:SAM
Last Name:GALLEGOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 DEXTER ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80220-2456
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1395 S PLATTE RIVER DR
Practice Address - Street 2:STAFFING
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80223-3467
Practice Address - Country:US
Practice Address - Phone:303-603-3020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-21
Last Update Date:2007-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health