Provider Demographics
NPI:1811321433
Name:GALLARDO, ANTONIO
Entity type:Individual
Prefix:
First Name:ANTONIO
Middle Name:
Last Name:GALLARDO
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:PO BOX 6371
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94403-6371
Mailing Address - Country:US
Mailing Address - Phone:650-679-4475
Mailing Address - Fax:
Practice Address - Street 1:216A SWETT RD
Practice Address - Street 2:
Practice Address - City:WOODSIDE
Practice Address - State:CA
Practice Address - Zip Code:94062-4752
Practice Address - Country:US
Practice Address - Phone:650-679-4475
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-30
Last Update Date:2013-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA75166101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health