Provider Demographics
NPI:1740847284
Name:FEDERICO, GLORIA ANN
Entity type:Individual
Prefix:MISS
First Name:GLORIA
Middle Name:ANN
Last Name:FEDERICO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3216 EVERDALE DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95148-3405
Mailing Address - Country:US
Mailing Address - Phone:408-771-2505
Mailing Address - Fax:
Practice Address - Street 1:39210 STATE ST.
Practice Address - Street 2:SUITE 220 FREMONT, CA 94538
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538
Practice Address - Country:US
Practice Address - Phone:510-894-4135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-21
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46-1305562106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician