Provider Demographics
NPI:1578170494
Name:GLADNEY, WILSONAIE MAXINE
Entity Type:Individual
Prefix:
First Name:WILSONAIE
Middle Name:MAXINE
Last Name:GLADNEY
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 1:13320 DOTY AVE APT 264
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-8923
Mailing Address - Country:US
Mailing Address - Phone:323-374-7820
Mailing Address - Fax:
Practice Address - Street 1:23842 HAWTHORNE BLVD STE 100101
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-5929
Practice Address - Country:US
Practice Address - Phone:424-328-5297
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-24
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAY4498605103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst