Provider Demographics
NPI:1588183560
Name:MCGLADE, ANASTASIA LARA (PHD)
Entity Type:Individual
Prefix:DR
First Name:ANASTASIA
Middle Name:LARA
Last Name:MCGLADE
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 1:11870 SANTA MONICA BLVD STE 106504
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-2276
Mailing Address - Country:US
Mailing Address - Phone:310-876-2619
Mailing Address - Fax:
Practice Address - Street 1:11870 SANTA MONICA BLVD STE 106504
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-2276
Practice Address - Country:US
Practice Address - Phone:310-876-2619
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-12
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY33611103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical