Basic Information
| Provider Information | |||||||||
| NPI: | 1114266004 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GALLEGOS | ||||||||
| FirstName: | DONNA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LMFT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | REYES-GONZALEZ | ||||||||
| OtherFirstName: | DONNA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 14651 KALISHER ST | ||||||||
| Address2: | |||||||||
| City: | SAN FERNANDO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913404113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8184700286 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11133 OMELVENY AVE | ||||||||
| Address2: | |||||||||
| City: | SAN FERNANDO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913404426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8183657517 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2013 | ||||||||
| LastUpdateDate: | 02/12/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | MFC-52753 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.