Provider Demographics
NPI:1780202523
Name:GLEASON, KEVIN CHRISTOPHER
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:CHRISTOPHER
Last Name:GLEASON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6666 GREEN VALLEY CIRCLE
Mailing Address - Street 2:CULVER CITY
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90230
Mailing Address - Country:US
Mailing Address - Phone:619-889-4308
Mailing Address - Fax:
Practice Address - Street 1:6666 GREEN VALLEY CIR
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90230-7068
Practice Address - Country:US
Practice Address - Phone:310-846-5270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-08
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator