Provider Demographics
NPI:1558480954
Name:GLADSTONE, SHEILA (MED)
Entity Type:Individual
Prefix:
First Name:SHEILA
Middle Name:
Last Name:GLADSTONE
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:292 MELROSE RD
Mailing Address - Street 2:
Mailing Address - City:MERION STATION
Mailing Address - State:PA
Mailing Address - Zip Code:19066-1716
Mailing Address - Country:US
Mailing Address - Phone:610-667-4191
Mailing Address - Fax:
Practice Address - Street 1:1601 WALNUT ST
Practice Address - Street 2:SUITE 806
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102-2944
Practice Address - Country:US
Practice Address - Phone:215-331-3200
Practice Address - Fax:215-331-3977
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS005260L103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA4058912000OtherMAGELLAN