Provider Demographics
NPI:1780424754
Name:GALLEGOS, ANDREA TERRY
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:TERRY
Last Name:GALLEGOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4025 N FRUIT AVE APT 218
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93705-2118
Mailing Address - Country:US
Mailing Address - Phone:559-807-1794
Mailing Address - Fax:
Practice Address - Street 1:4705 N SONORA AVE STE 113
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93722-3965
Practice Address - Country:US
Practice Address - Phone:559-276-7558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-28
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18567101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)