Provider Demographics
NPI:1659014660
Name:GRESHAM, GLENDA (MSW)
Entity Type:Individual
Prefix:MRS
First Name:GLENDA
Middle Name:
Last Name:GRESHAM
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 E 109TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-3705
Mailing Address - Country:US
Mailing Address - Phone:570-234-8066
Mailing Address - Fax:
Practice Address - Street 1:195 CHATHAM HILL RD
Practice Address - Street 2:
Practice Address - City:STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18360-6625
Practice Address - Country:US
Practice Address - Phone:646-841-4427
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-18
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY104000000XMedicaid
NY1041000000XMedicaid