Provider Demographics
NPI:1629101985
Name:FALLENTINE, GLORIA CHRISTINE (MFT)
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:CHRISTINE
Last Name:FALLENTINE
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:251 E HACKETT RD
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95358-9415
Mailing Address - Country:US
Mailing Address - Phone:209-558-2421
Mailing Address - Fax:209-558-3962
Practice Address - Street 1:251 E HACKETT RD
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95358-9415
Practice Address - Country:US
Practice Address - Phone:209-558-2421
Practice Address - Fax:209-558-3962
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 37507106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist