Provider Demographics
NPI:1730801259
Name:GALLEGOS, SAMUEL ADAM
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:ADAM
Last Name:GALLEGOS
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 1:4 AVIS AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81005-3102
Mailing Address - Country:US
Mailing Address - Phone:719-256-0127
Mailing Address - Fax:719-258-1327
Practice Address - Street 1:4 AVIS AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81005-3102
Practice Address - Country:US
Practice Address - Phone:719-256-0127
Practice Address - Fax:719-258-1327
Is Sole Proprietor?:No
Enumeration Date:2022-09-12
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor