Provider Demographics
NPI:1881701019
Name:FONDREN, GLORIA D (MA, LPC, LSOTP)
Entity type:Individual
Prefix:MRS
First Name:GLORIA
Middle Name:D
Last Name:FONDREN
Suffix:
Gender:F
Credentials:MA, LPC, LSOTP
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 689
Mailing Address - Street 2:
Mailing Address - City:LEAKEY
Mailing Address - State:TX
Mailing Address - Zip Code:78873-0689
Mailing Address - Country:US
Mailing Address - Phone:830-232-6590
Mailing Address - Fax:830-232-6522
Practice Address - Street 1:8500 VILLAGE DR
Practice Address - Street 2:SUITE 300
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78217-5510
Practice Address - Country:US
Practice Address - Phone:210-821-5311
Practice Address - Fax:210-826-1771
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16060101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX85278LOtherBCBS PROVIDER ID