Provider Demographics
NPI:1164619128
Name:CLEGHORN, GLORIA GAY (INDEPENDENT PROVIDER)
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:GAY
Last Name:CLEGHORN
Suffix:
Gender:F
Credentials:INDEPENDENT PROVIDER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 W THORNTON ST
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44307-1926
Mailing Address - Country:US
Mailing Address - Phone:330-434-1743
Mailing Address - Fax:888-328-5911
Practice Address - Street 1:405 W THORNTON ST
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44307-1926
Practice Address - Country:US
Practice Address - Phone:330-434-1743
Practice Address - Fax:888-328-5911
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-03
Last Update Date:2007-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRH167804171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0974307Medicaid