Healthcare Provider Details

I. General information

NPI: 1285665117
Provider Name (Legal Business Name): JOHANNA D GLADIEUX PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 11/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

954 RISA RD STE A
LAFAYETTE CA
94549-3418
US

IV. Provider business mailing address

835 TOPPER LN
LAFAYETTE CA
94549-5119
US

V. Phone/Fax

Practice location:
  • Phone: 510-332-0329
  • Fax:
Mailing address:
  • Phone: 925-283-9953
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY4858
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: