Healthcare Provider Details

I. General information

NPI: 1649409616
Provider Name (Legal Business Name): KENNETH ALAN GLADSTONE PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2009
Last Update Date: 08/14/2020
Certification Date: 08/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2019 17TH ST
SAN FRANCISCO CA
94103-5012
US

IV. Provider business mailing address

2019 17TH ST
SAN FRANCISCO CA
94103-5012
US

V. Phone/Fax

Practice location:
  • Phone: 415-745-2611
  • Fax:
Mailing address:
  • Phone: 415-745-2611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY26637
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: