Healthcare Provider Details

I. General information

NPI: 1902536469
Provider Name (Legal Business Name): MARY CANDACE GLADNEY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2022
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 COUNTRY CLUB DR
STOCKBRIDGE GA
30281-7349
US

IV. Provider business mailing address

213 EXPEDITION DR
ELLENWOOD GA
30294-2276
US

V. Phone/Fax

Practice location:
  • Phone: 770-474-8400
  • Fax:
Mailing address:
  • Phone: 678-216-8692
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW008121
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.2507089
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: