Provider Demographics
NPI:1013148162
Name:GLADSTEIN, MICHAEL JASON (EDS)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JASON
Last Name:GLADSTEIN
Suffix:
Gender:M
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1780 MAPLE ST STE 1
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60093-3021
Mailing Address - Country:US
Mailing Address - Phone:847-644-8005
Mailing Address - Fax:
Practice Address - Street 1:1780 MAPLE ST STE 1
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:IL
Practice Address - Zip Code:60093-3021
Practice Address - Country:US
Practice Address - Phone:847-644-8005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-06
Last Update Date:2009-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2243184-73103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool