Provider Demographics
NPI:1982021218
Name:GLADSTONE, KENNETH
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:GLADSTONE
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 1:1365 N JOHNSON AVE STE 111
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92020-1649
Mailing Address - Country:US
Mailing Address - Phone:619-440-4801
Mailing Address - Fax:619-442-1592
Practice Address - Street 1:1365 N JOHNSON AVE STE 111
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92020-1649
Practice Address - Country:US
Practice Address - Phone:619-440-4801
Practice Address - Fax:619-442-1592
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-25
Last Update Date:2014-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)