Provider Demographics
NPI:1649508169
Name:GALLEGOS, PAUL ANTHONY (BSW)
Entity type:Individual
Prefix:MR
First Name:PAUL
Middle Name:ANTHONY
Last Name:GALLEGOS
Suffix:
Gender:M
Credentials:BSW
Other - Prefix:MR
Other - First Name:PAUL
Other - Middle Name:ANTHONY
Other - Last Name:GALLEGOS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:BSW
Mailing Address - Street 1:130 W VICTORIA ST
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90248-3523
Mailing Address - Country:US
Mailing Address - Phone:562-754-1546
Mailing Address - Fax:
Practice Address - Street 1:130 W VICTORIA ST
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90248-3523
Practice Address - Country:US
Practice Address - Phone:562-754-1546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-20
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner