Provider Demographics
NPI:1346305794
Name:LAWRENCE, GLORIA LYNN
Entity Type:Individual
Prefix:DR
First Name:GLORIA
Middle Name:LYNN
Last Name:LAWRENCE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2734 RUSSELL ST
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94705-2318
Mailing Address - Country:US
Mailing Address - Phone:510-549-2539
Mailing Address - Fax:510-549-1203
Practice Address - Street 1:445 BELLEVUE AVE
Practice Address - Street 2:302
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94610-4923
Practice Address - Country:US
Practice Address - Phone:510-465-8919
Practice Address - Fax:510-549-1203
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY10650103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist