Provider Demographics
NPI:1205854874
Name:GLEASON, DIANA JEAN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:DIANA
Middle Name:JEAN
Last Name:GLEASON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1525 SHATTUCK AVE STE B
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94709-1500
Mailing Address - Country:US
Mailing Address - Phone:510-433-7273
Mailing Address - Fax:
Practice Address - Street 1:1525 SHATTUCK AVE STE B
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94709
Practice Address - Country:US
Practice Address - Phone:510-433-7273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY18254103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP91627Medicare UPIN
CA0PL182540Medicare ID - Type UnspecifiedPROVIDER ID