Provider Demographics
NPI:1346828019
Name:GLADDEN, DAISARA
Entity Type:Individual
Prefix:
First Name:DAISARA
Middle Name:
Last Name:GLADDEN
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 1:1099 EDMEYER CT
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44306-3721
Mailing Address - Country:US
Mailing Address - Phone:786-899-6390
Mailing Address - Fax:
Practice Address - Street 1:1099 EDMEYER CT
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44306-3721
Practice Address - Country:US
Practice Address - Phone:234-718-1133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-01
Last Update Date:2021-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
OH374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH85-1002110OtherIRS