Provider Demographics
NPI:1285665117
Name:GLADIEUX, JOHANNA D (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHANNA
Middle Name:D
Last Name:GLADIEUX
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:835 TOPPER LN
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CA
Mailing Address - Zip Code:94549-5119
Mailing Address - Country:US
Mailing Address - Phone:925-283-9953
Mailing Address - Fax:
Practice Address - Street 1:954 RISA RD STE A
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CA
Practice Address - Zip Code:94549-3418
Practice Address - Country:US
Practice Address - Phone:510-332-0329
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2009-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY4858103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACE059AOtherMEDICARE PTAN
CA0842125Medicare UPIN