Provider Demographics
NPI:1275999054
Name:GLADNEY, DAMON SR
Entity Type:Individual
Prefix:
First Name:DAMON
Middle Name:
Last Name:GLADNEY
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3510 LINWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-4512
Mailing Address - Country:US
Mailing Address - Phone:318-636-4194
Mailing Address - Fax:
Practice Address - Street 1:3510 LINWOOD AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4512
Practice Address - Country:US
Practice Address - Phone:318-636-4194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-08
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA25100000XMedicaid