Provider Demographics
NPI:1659117406
Name:GALLEGOS, LISA (BCBA)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:GALLEGOS
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 SILVER BAY RD
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08753-2551
Mailing Address - Country:US
Mailing Address - Phone:732-581-8739
Mailing Address - Fax:
Practice Address - Street 1:2312 WHITEHORSE MERCERVILLE RD STE 205
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:NJ
Practice Address - Zip Code:08619-1953
Practice Address - Country:US
Practice Address - Phone:609-643-9077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-02
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1-20-43238103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst