Healthcare Provider Details

I. General information

NPI: 1235642943
Provider Name (Legal Business Name): MATTHEW GLEASON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2017
Last Update Date: 09/07/2024
Certification Date: 09/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 W BRIGGSMORE AVE STE I
MODESTO CA
95350-3839
US

IV. Provider business mailing address

1904 RICHLAND AVE
CERES CA
95307-4562
US

V. Phone/Fax

Practice location:
  • Phone: 209-526-1440
  • Fax: 209-526-0908
Mailing address:
  • Phone: 209-494-2412
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number123468
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: