Provider Demographics
NPI:1386965176
Name:GALLEGOS, TRACY J (BA, CACIII)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:J
Last Name:GALLEGOS
Suffix:
Gender:M
Credentials:BA, CACIII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2708 PATTERSON RD
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81506-4031
Mailing Address - Country:US
Mailing Address - Phone:970-243-9539
Mailing Address - Fax:970-245-7493
Practice Address - Street 1:2708 PATTERSON RD
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81506-4031
Practice Address - Country:US
Practice Address - Phone:970-243-9539
Practice Address - Fax:970-245-7493
Is Sole Proprietor?:No
Enumeration Date:2010-06-16
Last Update Date:2024-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YP2500X, 101YM0800X
COACC.0020787101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health