Provider Demographics
NPI: | 1013214691 |
---|---|
Name: | GAINES, GLADYS A |
Entity Type: | Individual |
Prefix: | MS |
First Name: | GLADYS |
Middle Name: | A |
Last Name: | GAINES |
Suffix: | |
Gender: | F |
Credentials: | |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | PO BOX 1162 |
Mailing Address - Street 2: | |
Mailing Address - City: | BOWLING GREEN |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 33834-1162 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 863-253-7510 |
Mailing Address - Fax: | 863-386-9117 |
Practice Address - Street 1: | 5109 STURGEON DR |
Practice Address - Street 2: | |
Practice Address - City: | SEBRING |
Practice Address - State: | FL |
Practice Address - Zip Code: | 33870-1173 |
Practice Address - Country: | US |
Practice Address - Phone: | 863-253-7510 |
Practice Address - Fax: | 863-386-9117 |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2011-02-17 |
Last Update Date: | 2011-03-19 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
103TA0700X, 251E00000X, 252Y00000X, 253Z00000X, 251300000X, 343900000X, 385HR2060X, 390200000X, 320700000X, 320800000X | ||
FL | 103TS0200X, 172A00000X, 222Q00000X, 251C00000X, 322D00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 320800000X | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness | |
No | 103TA0700X | Behavioral Health & Social Service Providers | Psychologist | Adult Development & Aging |
No | 251E00000X | Agencies | Home Health | |
No | 252Y00000X | Agencies | Early Intervention Provider Agency | |
No | 253Z00000X | Agencies | In Home Supportive Care | |
No | 251300000X | Agencies | Local Education Agency (LEA) | |
No | 343900000X | Transportation Services | Non-emergency Medical Transport (VAN) | |
No | 385HR2060X | Respite Care Facility | Respite Care | Respite Care, Intellectual and/or Developmental Disabilities, Child |
No | 390200000X | Student, Health Care | Student in an Organized Health Care Education/Training Program | |
No | 103TS0200X | Behavioral Health & Social Service Providers | Psychologist | School |
No | 172A00000X | Other Service Providers | Driver | |
No | 222Q00000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Developmental Therapist | |
No | 251C00000X | Agencies | Day Training, Developmentally Disabled Services | |
No | 320700000X | Residential Treatment Facilities | Residential Treatment Facility, Physical Disabilities | |
No | 322D00000X | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
FL | 000309700 | Medicaid | |
FL | 002313900 | Medicaid | |
FL | 002536200 | Medicaid | |
FL | 000630100 | Medicaid | |
FL | 002313600 | Medicaid |