Provider Demographics
NPI:1114566437
Name:GLEASON, MEREDITH (LEP)
Entity Type:Individual
Prefix:
First Name:MEREDITH
Middle Name:
Last Name:GLEASON
Suffix:
Gender:F
Credentials:LEP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9921 CARMEL MOUNTAIN RD # 370
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92129-2813
Mailing Address - Country:US
Mailing Address - Phone:310-703-3638
Mailing Address - Fax:
Practice Address - Street 1:11622 EL CAMINO REAL STE 100
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-2051
Practice Address - Country:US
Practice Address - Phone:310-703-3638
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-03
Last Update Date:2020-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3847103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool