Provider Demographics
NPI:1689085037
Name:GLEASON, CARRIE (LP)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:
Last Name:GLEASON
Suffix:
Gender:F
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 W UNIVERSITY DR STE B-3
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48307-1817
Mailing Address - Country:US
Mailing Address - Phone:248-854-5520
Mailing Address - Fax:
Practice Address - Street 1:900 W UNIVERSITY DR STE B-3
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MI
Practice Address - Zip Code:48307-1817
Practice Address - Country:US
Practice Address - Phone:248-854-5520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-19
Last Update Date:2017-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301012777103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist