Provider Demographics
NPI:1144099284
Name:GALLEGOS, KIRSTEN
Entity type:Individual
Prefix:MISS
First Name:KIRSTEN
Middle Name:
Last Name:GALLEGOS
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:KERSTINE
Other - Middle Name:
Other - Last Name:GALLEGOS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3807 35TH CIR SE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-1805
Mailing Address - Country:US
Mailing Address - Phone:505-353-7926
Mailing Address - Fax:
Practice Address - Street 1:1207 GOLF COURSE RD SE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-1999
Practice Address - Country:US
Practice Address - Phone:505-994-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-01
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCTB-2024-0065101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty