Provider Demographics
NPI:1922702711
Name:GALLAGHER, MARK ANTHONY SORIANO (390200000X)
Entity type:Individual
Prefix:
First Name:MARK ANTHONY
Middle Name:SORIANO
Last Name:GALLAGHER
Suffix:
Gender:M
Credentials:390200000X
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6915 PARKSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92139-3891
Mailing Address - Country:US
Mailing Address - Phone:619-764-3925
Mailing Address - Fax:
Practice Address - Street 1:1660 HOTEL CIR N STE 101
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-2801
Practice Address - Country:US
Practice Address - Phone:619-961-2120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-28
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician