Provider Demographics
NPI:1720596323
Name:GALLESE, MICHAEL
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:GALLESE
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 1:32158 CAMINO CAPISTRANO STE 104-802
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN CAPISTRANO
Mailing Address - State:CA
Mailing Address - Zip Code:92675-3720
Mailing Address - Country:US
Mailing Address - Phone:424-257-0746
Mailing Address - Fax:
Practice Address - Street 1:32158 CAMINO CAPISTRANO STE 104-802
Practice Address - Street 2:
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675-3720
Practice Address - Country:US
Practice Address - Phone:424-257-0746
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-17
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13892101YM0800X
CAR1454740122101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)