Provider Demographics
NPI:1942367776
Name:GLADSTONE, MARSHALL (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARSHALL
Middle Name:
Last Name:GLADSTONE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 N MAIN ST
Mailing Address - Street 2:THIRD FLOOR
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06107-1970
Mailing Address - Country:US
Mailing Address - Phone:860-561-1662
Mailing Address - Fax:860-561-1723
Practice Address - Street 1:18 N MAIN ST
Practice Address - Street 2:THIRD FLOOR
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107-1970
Practice Address - Country:US
Practice Address - Phone:860-561-1662
Practice Address - Fax:860-561-1723
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001469103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist