Provider Demographics
NPI:1396090585
Name:GLEASON, MARK K
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:K
Last Name:GLEASON
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 1:516 ROYAL ST
Mailing Address - Street 2:
Mailing Address - City:NATCHITOCHES
Mailing Address - State:LA
Mailing Address - Zip Code:71457-5713
Mailing Address - Country:US
Mailing Address - Phone:318-289-8806
Mailing Address - Fax:
Practice Address - Street 1:516 ROYAL ST
Practice Address - Street 2:
Practice Address - City:NATCHITOCHES
Practice Address - State:LA
Practice Address - Zip Code:71457-5713
Practice Address - Country:US
Practice Address - Phone:318-289-8806
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-13
Last Update Date:2012-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAZ11531225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAPENDINGMedicare PIN