Provider Demographics
NPI:1205991957
Name:GALLEGOS, RAFAEL (PSYD)
Entity type:Individual
Prefix:DR
First Name:RAFAEL
Middle Name:
Last Name:GALLEGOS
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 1:846 FARMINGTON AVE STE 11
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06119-1554
Mailing Address - Country:US
Mailing Address - Phone:860-236-7333
Mailing Address - Fax:
Practice Address - Street 1:846 FARMINGTON AVE STE 11
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06119-1554
Practice Address - Country:US
Practice Address - Phone:860-236-7333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002394103TB0200X, 103TC0700X, 103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic