Provider Demographics
NPI:1487251203
Name:GALLEGO ESPINOSA, ISRAEL MANUEL
Entity type:Individual
Prefix:
First Name:ISRAEL
Middle Name:MANUEL
Last Name:GALLEGO ESPINOSA
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 1:9201 NW 114TH ST APT 5
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33018-4302
Mailing Address - Country:US
Mailing Address - Phone:786-806-7529
Mailing Address - Fax:
Practice Address - Street 1:9201 NW 114TH ST APT 5
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33018-4302
Practice Address - Country:US
Practice Address - Phone:786-806-7529
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-05
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20-128968106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty