Provider Demographics
NPI:1508193491
Name:PALECEK, GLORY ANN (PHD)
Entity Type:Individual
Prefix:DR
First Name:GLORY
Middle Name:ANN
Last Name:PALECEK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 H AVE
Mailing Address - Street 2:
Mailing Address - City:CORONADO
Mailing Address - State:CA
Mailing Address - Zip Code:92118-1222
Mailing Address - Country:US
Mailing Address - Phone:619-519-2554
Mailing Address - Fax:619-435-7717
Practice Address - Street 1:260 H AVE
Practice Address - Street 2:
Practice Address - City:CORONADO
Practice Address - State:CA
Practice Address - Zip Code:92118-1222
Practice Address - Country:US
Practice Address - Phone:619-519-2554
Practice Address - Fax:619-437-0225
Is Sole Proprietor?:No
Enumeration Date:2009-11-12
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY7272103TA0400X, 103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1508193491OtherTRICARE