Provider Demographics
NPI:1043974983
Name:GALLEGOS, MIA
Entity type:Individual
Prefix:
First Name:MIA
Middle Name:
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 1:1103 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:IMMOKALEE
Mailing Address - State:FL
Mailing Address - Zip Code:34142-2259
Mailing Address - Country:US
Mailing Address - Phone:239-503-0863
Mailing Address - Fax:
Practice Address - Street 1:1103 MONROE ST
Practice Address - Street 2:
Practice Address - City:IMMOKALEE
Practice Address - State:FL
Practice Address - Zip Code:34142-2259
Practice Address - Country:US
Practice Address - Phone:239-503-0863
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-27
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-24-72857103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst