Provider Demographics
NPI:1497471635
Name:STATEN, GLADYS CARLA
Entity Type:Individual
Prefix:
First Name:GLADYS
Middle Name:CARLA
Last Name:STATEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CARLA
Other - Middle Name:
Other - Last Name:STATEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 148
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:MS
Mailing Address - Zip Code:38851-0148
Mailing Address - Country:US
Mailing Address - Phone:662-794-2878
Mailing Address - Fax:662-456-1269
Practice Address - Street 1:101 KYLE DR STE 2
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:MS
Practice Address - Zip Code:38851-2717
Practice Address - Country:US
Practice Address - Phone:662-794-2878
Practice Address - Fax:662-456-1269
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-19
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT1168225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist