Provider Demographics
NPI:1437633625
Name:HALL, GLADYS V (CDCA167175)
Entity Type:Individual
Prefix:
First Name:GLADYS
Middle Name:V
Last Name:HALL
Suffix:
Gender:F
Credentials:CDCA167175
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25484 CONCORD DR
Mailing Address - Street 2:
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-6023
Mailing Address - Country:US
Mailing Address - Phone:216-409-3717
Mailing Address - Fax:
Practice Address - Street 1:5209 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44103-3703
Practice Address - Country:US
Practice Address - Phone:216-881-0765
Practice Address - Fax:216-431-2190
Is Sole Proprietor?:No
Enumeration Date:2018-09-24
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.167175101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)