Provider Demographics
NPI:1285816215
Name:CEBALLOS-LOGAN, GLADYS B (NMD)
Entity Type:Individual
Prefix:DR
First Name:GLADYS
Middle Name:B
Last Name:CEBALLOS-LOGAN
Suffix:
Gender:F
Credentials:NMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1757 E BASELINE RD
Mailing Address - Street 2:BLDG 9 STE 135
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85233-1532
Mailing Address - Country:US
Mailing Address - Phone:480-503-4325
Mailing Address - Fax:480-503-4326
Practice Address - Street 1:1757 E BASELINE RD
Practice Address - Street 2:BLDG 9 STE 135
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85233-1532
Practice Address - Country:US
Practice Address - Phone:480-503-4325
Practice Address - Fax:480-503-4326
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-30
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ03-752175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath