Provider Demographics
NPI:1588430912
Name:GALLEGOS, BOANERGES
Entity type:Individual
Prefix:
First Name:BOANERGES
Middle Name:
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 1:12027 STANSBURY DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79928-8620
Mailing Address - Country:US
Mailing Address - Phone:915-500-9229
Mailing Address - Fax:
Practice Address - Street 1:12330 PELLICANO DRIVE SUITE B
Practice Address - Street 2:SUITE B
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-8620
Practice Address - Country:US
Practice Address - Phone:915-613-5255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-27
Last Update Date:2024-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician