Provider Demographics
NPI:1225166879
Name:GLADSON, MARITA JOY (MFT)
Entity Type:Individual
Prefix:
First Name:MARITA
Middle Name:JOY
Last Name:GLADSON
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1845 W SOUTHGATE AVE
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92833-3733
Mailing Address - Country:US
Mailing Address - Phone:717-773-5172
Mailing Address - Fax:
Practice Address - Street 1:2226 N STATE COLLEGE BLVD
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92831-1361
Practice Address - Country:US
Practice Address - Phone:714-255-1668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 34779106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist