Provider Demographics
NPI:1144594615
Name:GLADMON, TRACEY DAVIS (LCSW-C)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:DAVIS
Last Name:GLADMON
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 N MAIN ST STE C
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:MD
Mailing Address - Zip Code:21811-1062
Mailing Address - Country:US
Mailing Address - Phone:410-641-4598
Mailing Address - Fax:410-641-4696
Practice Address - Street 1:124 N MAIN ST STE C
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:MD
Practice Address - Zip Code:21811-1062
Practice Address - Country:US
Practice Address - Phone:410-641-4598
Practice Address - Fax:410-641-4696
Is Sole Proprietor?:No
Enumeration Date:2012-03-01
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD12741101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional