Provider Demographics
NPI:1295947265
Name:COLTHARP, GLORIA (MSW, LCSW, BCD, ACSW)
Entity type:Individual
Prefix:MS
First Name:GLORIA
Middle Name:
Last Name:COLTHARP
Suffix:
Gender:F
Credentials:MSW, LCSW, BCD, ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 217035
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28221-0035
Mailing Address - Country:US
Mailing Address - Phone:704-372-0020
Mailing Address - Fax:704-358-0876
Practice Address - Street 1:2237 PARK RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5922
Practice Address - Country:US
Practice Address - Phone:704-372-0020
Practice Address - Fax:704-358-0876
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0004311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2861036Medicare ID - Type Unspecified