Provider Demographics
NPI:1316156938
Name:GALLEGOS, RONALD ANSELMO (PHD)
Entity type:Individual
Prefix:DR
First Name:RONALD
Middle Name:ANSELMO
Last Name:GALLEGOS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:194 CALLE VISTA GRANDE
Mailing Address - Street 2:
Mailing Address - City:BERNALILLO
Mailing Address - State:NM
Mailing Address - Zip Code:87004-6066
Mailing Address - Country:US
Mailing Address - Phone:505-401-2109
Mailing Address - Fax:
Practice Address - Street 1:3214 PURDUE PL NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-2124
Practice Address - Country:US
Practice Address - Phone:505-401-2109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM423103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMN0195Medicaid