Provider Demographics
NPI:1225853146
Name:GALLEGOS, MISAEL (COTA/L)
Entity type:Individual
Prefix:
First Name:MISAEL
Middle Name:
Last Name:GALLEGOS
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25755 RITTER AVE
Mailing Address - Street 2:
Mailing Address - City:HOMELAND
Mailing Address - State:CA
Mailing Address - Zip Code:92548-9280
Mailing Address - Country:US
Mailing Address - Phone:562-322-2143
Mailing Address - Fax:
Practice Address - Street 1:18270 SISKIYOU RD # B
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-1413
Practice Address - Country:US
Practice Address - Phone:760-991-3020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-15
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7004224ZF0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224ZF0002XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantFeeding, Eating & Swallowing