Provider Demographics
NPI:1457538183
Name:GLANDON, TERA
Entity Type:Individual
Prefix:
First Name:TERA
Middle Name:
Last Name:GLANDON
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:TERA
Other - Middle Name:
Other - Last Name:GLANDON-YARNELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:500 N 9TH ST STE C
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-5814
Mailing Address - Country:US
Mailing Address - Phone:209-558-4420
Mailing Address - Fax:
Practice Address - Street 1:500 N 9TH ST STE C
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-5814
Practice Address - Country:US
Practice Address - Phone:209-558-4420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-24
Last Update Date:2013-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA03-127497101YA0400X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
101YA0400XOtherCST