Healthcare Provider Details

I. General information

NPI: 1295081545
Provider Name (Legal Business Name): PHARA GLADDEN LCSW-R
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2012
Last Update Date: 07/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36 WEST HICKORY STREET
SPRING VALLEY NY
10977
US

IV. Provider business mailing address

P.O. BOX 105
BLAUVELT NY
10913
US

V. Phone/Fax

Practice location:
  • Phone: 845-596-8006
  • Fax:
Mailing address:
  • Phone: 845-596-8006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberR-075198
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: