Provider Demographics
NPI:1811560345
Name:GLADSTONE, THERESA (MA)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:GLADSTONE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 LYMAN CIR
Mailing Address - Street 2:
Mailing Address - City:SHAKER HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44122-2111
Mailing Address - Country:US
Mailing Address - Phone:216-218-0331
Mailing Address - Fax:
Practice Address - Street 1:22001 FAIRMOUNT BLVD
Practice Address - Street 2:
Practice Address - City:SHAKER HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44118-4819
Practice Address - Country:US
Practice Address - Phone:216-218-0331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-22
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty